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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803298
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:23:35 PM

Document Has Been Signed on 07/22/2022 02:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:House Manager, Debra JacksonTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Kellys Family Care #2 for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, House Manager, Debra Jackson and granted access into the facility. LPA observed minimal signs on the front door regarding COVID-19 (See LIC 9102).

LPA toured the facility with the House Manager, Debra Jackson and observed that the facility was at a comfortable temperature and was well lit. Hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature measured at 119 degrees within acceptable range of 105-120 degrees. Medications were centrally stored and locked. Cleaning products and other toxins are located in the bathroom and locked. Fire extinguisher was last charged on November 2021. Smoke Detectors and Carbon Monoxide Detectors were found to be operational during the inspection. First Aid kit was found to be appropriate during the inspection. There was a sufficient supply of both perishable and non-perishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. There was a supply of cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supplies stored in the locked in the closet. Facility is not N95 Fit tested (See LIC 9102).

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KELLYS FAMILY CARE #2
FACILITY NUMBER: 486803298
VISIT DATE: 07/22/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents


No deficiencies observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and emailed to the Administrator due to printer issues.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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