<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800049
Report Date: 04/13/2026
Date Signed: 04/13/2026 10:35:00 AM

Document Has Been Signed on 04/13/2026 10:35 AM - 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: 4DATE:
04/13/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Regyna Jackson-Branchcomb - AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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
At approximately 9:40 AM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced on a case management visit and met with Administrator Regyna Jackson-Branchcomb. Today's case management visit is related to a Report of Suspected Dependent Adult Abuse (SOC341) received by Community Care Licensing (Department) on 12/05/2025. In addition on 12/08/2025, the Department received a separate Unusual Incident/Injury Report (LIC624) report from Rachel Brown Family Care Home (RBFCH) indicating client (C1) had sustained severe injuries while inside RBFCH, the origin of which could not be described by the staff at RBFCH and required hospitalization of C1 beginning on 12/06/2025.

The Department made observations, conducted interviews and record review including medical and police records.

Record review revealed that a Physicians Report (LIC602) dating back to 03/26/2019 indicated C1 “requires fall supervision while bathing”, under the heading of “baths self? yes or no”

An Appraisal/Needs and Service Plan (LIC625) dated 06/17/2025 indicates,
“C1’s motor coordination and balance declined and negatively impacted (C1’s) ability to complete Activities of Daily Living (ADLS). Staff are responsible for assisting C1 in the following: Any medical orders and ensuring the C1 sees their medical staff as needed. C1 requires some level of assistance in all ADLs”

A North Bay Regional Center (NBRC) Individual Program Plan dated 08/23/2023 indicates, “C1 requires reminders and assistance to bathe, C1 has an unsteady balance and needs supervision while bathing”
Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: 04/13/2026
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
26
27
28
29
30
31
32
Continued from LIC809
An interview with S2 by the Department indicated that at least S2 “was responsible for assisting residents with their ADL such as eating meals, bathing, toileting, general grooming and cleaning with S2 indicating C1 was able to self-bathe and self-toilet with standby supervision.

An interview with S1 had S1 acknowledge that S1 and staff should have been aware of C1’s injuries and recognized that C1 was not being supervised when C1 sustained their injuries. In addition, S1 indicated that a second client (C2) “has a history of physical outbursts.”

Because the facility failed to follow the Care Plan for C1, the facility is being cited a Type B violation of Title 22 code 85078(a)(1) which requires, “The licensee to provide those services identified in the client’s needs and service plan as necessary to meet the client’s needs” (See LIC809-D page)

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

This report was reviewed with Administrator Regyna Jackson-Branchcomb and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/13/2026 10:35 AM - It Cannot Be Edited


Created By: Star Stevenson On 04/13/2026 at 09:52 AM
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: 04/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2026
Section Cited
CCR
85078(a)(1)

1
2
3
4
5
6
7
85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services indentified in the client's needs and service plan as necessary to meet the client's needs. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility will submit proof of all staff reviewing all clients in care (four) (4) latest LIC602, Care Plans and latest IPP/addendums. In addition facility will submit proof of training on review of regulation 85078 and all it's contents by Plan Of Care Due date 04/24/2026
8
9
10
11
12
13
14
Based on the Department's record review and interviews, there was a lack of supervision for client C1, staff failed to properly supervise client in care. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4