486800049-7-25-2023-21-AS-CFOR-CU3UFV-20230725153323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800049
Report Date: 07/25/2023
Date Signed: 07/25/2023 03:33:33 PM

Document Has Been Signed on 07/25/2023 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	RACHEL BROWNS' FAMILY CARE HOME		FACILITY NUMBER:	486800049
ADMINISTRATOR:	REGYNA JACKSON-BRANCHCOMB		FACILITY TYPE:	735
ADDRESS:	663 TABOR AVENUE		TELEPHONE:	(707) 425-0774
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 6	DATE:	07/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Regyna Jackson-Branchcomb, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), C. Fowler conducted a Required-1 Year inspection, on 7/25/23 at approximately 09:30am, and met with Administrator Regyna Jackson-Branchcomb. LPA observed Administrator was on duty during the inspection. Currently six (6) clients in care. Facility has an approved fire clearance four (4) ambulatory clients and 2 non-ambulatory clients. The facility has required emergency disaster plan. Facility had an evacuation fire drill on 07/03/23, including staff & clients. Clients have no special diets regarding food, per staff interviews, and per LPA's observations during the inspection. The LPA reviewed four(4) staff files. Administrator certificate for Regyna Jackson-Branchcomb is Administrator certificate is currently expired 6044328735 5/4/2023 Administrator has completed continuing education and paid fees for renewal. Administrator Rachel Brown certificate - 6015810735 is current and expires on 07/16/2024. All staff have required criminal record clearance. All staff have required training. The LPA reviewed five (5) client files. Client files were complete. Five (5) of six (6) clients and their families maintain their monies. Funds for C1 is maintained and not mixed with facility funds/any other funds. The LPA toured the facility with the Administrator. All exits were unobstructed. The facility fire extinguisher was serviced and tagged as required expires 10/12/23. Facility had (3) smoke alarms, and all were working properly when checked during the inspection. Facility has one (1) carbon monoxide detector that were working properly when checked during the inspection. Facility has 2 first aid kits locked and stored in the hallway storage, it did have a required first aid booklet. The facility had a sufficient supply of perishable and nonperishable food. Continued on LIC809C.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2023 03:33 PM - It Cannot Be Edited

Created By: Carol Fowler On 07/25/2023 at 02:05 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RACHEL BROWNS' FAMILY CARE HOME	FACILITY NUMBER: 486800049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80076(a)(16)

Food Service

(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having Cleaners/toxins in a unlocked cabinet located in the kitchen which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/26/2023
	Plan of Correction
1 2 3 4	Administrator to review and understand the regulation and email self certification to CCLD no later than 7/26/2023

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kimberley Mota

LICENSING EVALUATOR NAME:

Carol Fowler

LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RACHEL BROWNS' FAMILY CARE HOME	FACILITY NUMBER: 486800049
	VISIT DATE: 07/25/2023

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CONTINUE FROM LIC809
The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be clean and orderly during the visit. The LPA observed that resident rooms, and bathrooms had sufficient lighting for clients in care, however the hallway light bulb will need to be replaced with a higher watt light bulb. Clients rooms had required accommodations per regulations. Facility had all medications locked up and inaccessible to clients in care as required. During tour LPA observed facility had cleaners/toxins accessible to clients in care as required.

LPA is requesting the following forms be updated and submitted to CCL by 8/04/23:

· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificate
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond in Required Amount
· Infection Control Plan If updated

During tour LPA observed the following deficiency:
Facility had cleaners/toxins accessible to clients in care.
· Cleaners/toxins were moved and locked during visit.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC809 (FAS) - (06/04)

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