486803298-8-26-2021-21-AS-KLOZ-C69TZL-20210826151032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803298
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:10:56 PM

Document Has Been Signed on 08/26/2021 03:10 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	KELLYS FAMILY CARE #2		FACILITY NUMBER:	486803298
ADMINISTRATOR:	CUPID, ALMA		FACILITY TYPE:	735
ADDRESS:	2504 SUNRISE DRIVE		TELEPHONE:	(707) 421-2950
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 5		CENSUS: 3	DATE:	08/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Debra Jackson, House Manager		TIME COMPLETED:	03:19 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Karen Lopez and Karina Canela conducted an unannounced Required 1 year inspection to Kelly’s Family Care #2 and was welcomed by House Manager, Debra Jackson. LPAs conducted a Risk Assessment call with staff Debra Jackson prior to the visit. There were 3 clients present.
LPAs toured the facility on August 26, 2021 with staff Debra Jackson, and all exits were free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was charged and serviced on October 8, 2020 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Perishable and nonperishable food supply was within regulation. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available.

COVID-19 precaution postings were observed throughout the facility. LPAs discussed implementing a designated screening station specific to COVID-19 to include a sign-in sheet for staff and visitors, thermometer, hand sanitizer, and a COVID-19 screening questionnaire. Staff and client temperatures are taken once daily and LPA observed documentation.

LPAs discussed with Debra Jackson documenting staff training on PPE use, isolation policies, and infection prevention. N-95 respirator Fit testing (Cal/OSHA requirement) is in process. LPA observed a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. LPA discussed with Debra Jackson to ensure all staff wear face masks when at the facility.

Report continued on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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 08/26/2021 03:10 PM - It Cannot Be Edited

Created By: Karen Lopez On 08/26/2021 at 10:57 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: KELLYS FAMILY CARE #2	FACILITY NUMBER: 486803298
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/27/2021 Section Cited	1 2 3 4 5 6 7	80019(e)(3) Criminal Record Clearance- (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: 3) Request and be approved for a transfer of a criminal record exemption...This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on LPA's observation, interviews & record review during today's visit: Licensee did not ensure the regulation above due to I1 who has not requested and obtained an approved transfer for a criminal record exemption to this facility as required. This is an immediate risk to the Health & Safety of clients in care.	8 9 10 11 12 13 14	Facility to submit a written statement they understand regulation 80019(e)(3) and will be in future compliance. Facility to submit statements to CCL by POC due date 08/27/2021. **Civil Penalty assessed in the total amount of $100.00
	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.

SUPERVISOR'S NAME:

Bethany Moellers

LICENSING EVALUATOR NAME:

Karen Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: KELLYS FAMILY CARE #2	FACILITY NUMBER: 486803298
	VISIT DATE: 08/26/2021

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During the inspection, LPA Lopez encountered staff's dog who bit LPA's boot. LPA Canela had a similar encounter with the same dog during an Annual Required Inspection on 11/13/2019 in which the dog bit LPA. LPAs will discuss with a manager regarding this and follow up with the facility at a later time.

During the inspection, LPAs observed individual (I1) to be present at the facility. LPAs verified in the facility Personal Report/Roster in Guardian that I1 is not associated to Kelly's Family Care #2. House Manager stated they previously submitted paperwork to process a criminal record exemption request but the documents were not received and believed the exemption request for I1 was denied. House Manager stated I1 no longer works at the facility or provides care to clients but will sometimes drop off items to the House Manger. Interviews indicated I1 resides at the facility. LPA Canela previously spoke and notified Licensee Alma Cupid on 05/24/2021 regarding I1's Case Closure dated 05/21/2021 and Licensee stated she understood. Licensee was not available during time of inspection.

LPAs explained prior to anyone working, volunteering, residing or being present in any part of the facility they are required to be fingerprint cleared and associated to the facility. LPAs explained Community Care Licensing (CCL) requirements and provided the regulation for criminal record exemptions. House Manger stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at Kelly's Family Care #2, the individual must obtain a fingerprint clearance, be associated to the facility, and request and obtain a transfer for a criminal record exemption if needed.

Civil penalty in the total amount of $100.00 was issued today for individual (I1) who did not request an approved transfer for a criminal record exemption to this facility as required.

Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with House Manager Debra Jackson, whose signature below confirms receipt of report.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

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