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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803298
Report Date: 09/03/2021
Date Signed: 09/24/2021 02:07:53 PM

Document Has Been Signed on 09/24/2021 02:07 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 #2FACILITY NUMBER:
486803298
ADMINISTRATOR:CUPID, ALMAFACILITY TYPE:
735
ADDRESS:2504 SUNRISE DRIVETELEPHONE:
(707) 421-2950
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 3DATE:
09/03/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alma Cupid, Licensee & Debra Jackson, House ManagerTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Lopez and Licensing Program Manager (LPM) Bethany Moellers met via tele-visit with Licensee, Alma Cupid and House Manager, Debra Jackson. This office meeting was conducted via tele-visit.

The purpose of today's office meeting was to discuss incident that occurred on 8/26/2021. On 8/26/21, LPA Lopez was bit by facility dog. LPA Lopez and LPM Moellars discussed plan on how to prevent similar incidents from happening. Licensee and House Manager agreed to write a plan and send to LPA Lopez via email. LPA Lopez also reviewed Technical Assistances from Annual Inspection on 8/26/21. In addition, Licensee and House Manager agreed that I1 would not be present in facility unless exemption is approved.

No deficiencies cited during this meeting.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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