Senior Care Records.

Facility Evaluation Report

Hickory House, San Rafael02/28/2025Licence 216800419

Capacity6
Census5
Date signed02/28/2025 03:16:12 PM
The inspector’s account

At approximately 2:20PM, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to conduct a Required 1 Year visit and met with Administrator, Lakeda Brown-Steward. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPAs were informed that there were 5 clients in care with 4 clients out of the facility attending Day Program.

At approximately 2:30PM, LPAs conducted a walk-through of the facility with Administrator. LPAs observed the following: The facility was found to be clean and at a comfortable temperature. Facility is a one story building with 4 Client bedrooms, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Emergency water supply was observed as well as emergency lighting and supplies. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were measured within Title 22 regulations of 105 degree to 120 degrees Fahrenheit.

Carbon Dioxide and Smoke Detectors were tested and operational during visit. Fire extinguishers were observed charged and last serviced April 2024. Facility has a swimming pool that was observed to be locked. Construction was observed in the garage to create a new staff room and facility storage. Per conversation with Administrator, once the new structures have been completed facility will submit a new facility sketch to CCL with updated labels.

LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Exit interview conducted with Administrator and a copy of this report was given.

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction