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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800049
Report Date: 08/22/2024
Date Signed: 08/22/2024 04:18:52 PM

Document Has Been Signed on 08/22/2024 04:18 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 HOMEFACILITY NUMBER:
486800049
ADMINISTRATOR/
DIRECTOR:		REGYNA JACKSON-BRANCHCOMBFACILITY TYPE:
735
ADDRESS:663 TABOR AVENUETELEPHONE:
(707) 425-0774
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Rachel Brown, Licensee and Regyna Jackson-Branchcomb, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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At approximately 9:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by staff (S1). Licensee was contacted at approximately 9:20 and informed LPA that Regyna Jackson-Branchcomb, Administrator was away at an appointment. Licensee stated they would come to the facility for today's inspection and arrived at approximately 10:10 AM. LPA waited in state vehicle and worked on paperwork until Licensee arrived. Administrator later arrived at 11:20 AM. Facility is an Adult Residential Facility with five (5) ambulatory clients in care. LPA was informed that three (3) clients left for Day Program; two (2) clients were present during visit. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 10:20 AM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a deck and seating area in the backyard with outdoor space for activities. LPA observed an activity schedule and clients have games in their bedrooms. Facility has internet available to clients in care and the phone was tested an operational. Facility does not currently have an internet access device available to clients in care as it has been a documented problem in the facility in the past. LPA informed Administrator of the need to have a device available for client use. Administrator agreed to purchase one.

Facility's fire extinguisher was observed charged and was last serviced November 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, and the most recent drill was conducted August 2024.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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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: 08/22/2024
NARRATIVE
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Continued from LIC809...

LPA observed facility's infection control plan and emergency disaster plan which was last updated January 2024. LPA observed a supply of PPE, emergency supplies, flashlights, and a first aid kit for emergency preparedness. Administrator states the facility does not have a backup generator.

At approximately 11:30 AM, LPA reviewed five (5) staff files and five (5) client files. Five (5) of five (5) staff files reviewed have proof of current CPR and First Aid certificates. Four (4) of five (5) staff files reviewed have the required paperwork. However, S2 and S3 need to sign their LIC501 Personnel Record/Application. Additionally, one (1) of five (5) staff (S4) does not have a LIC503 Health Screening in their file. Administrator agreed to bring both into compliance immediately. Four (4) of five (5) client (C1-C4) files reviewed were missing the client's Consent for Emergency Medical Treatment. Five (5) of five (5) client files reviewed had all the remaining required documents. Administrator coordinates medical and dental visits for the clients and takes them to their appointments.

At approximately 1:00 PM, LPA reviewed medications and medication records which are maintained in compliance with regulation. Per Administrator, facility does not manage cash resources for the clients.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC610D - updated
LIC500 - updated
A copy of Property Deed

Deficiencies were cited during today's inspection. (See LIC809D).

**An Immediate Civil Penalty in the total amount of $500 is being assessed for the observed exit door in two (2) client bedrooms which were locked requiring a key to unlock from both sides, which is a fire clearance violation and immediate health, safety, and/or personal rights violation to persons in care. (See LIC421IM).**

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/22/2024 04:18 PM - It Cannot Be Edited


Created By: Julie Florio On 08/22/2024 at 03:31 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: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 client bedroom exit doors locked with key access only on both sides of the doors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee shall submit pictures of the key locks removed from the exit door in both client bedrooms with locked doors to CCL by POC due date 8/23/2024. This is a fire clearance violation with an immediate civil penalty issued in the amount of $500 during today's inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/22/2024 04:18 PM - It Cannot Be Edited


Created By: Julie Florio On 08/22/2024 at 03:31 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: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ensuring non-slip mats in the tile shower in both client bathrooms, wall shelf in C1's bedroom is secured to the wall, and a missing window screen in one client bedroom. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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LIcensee to submit picture proof that the above mentioned deficiedcies have been corrected to CCL by POC due date 9/13/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
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: 08/22/2024
NARRATIVE
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Continued from LIC809C...

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 with Administrator and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6