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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803298
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:33:09 PM

Document Has Been Signed on 09/21/2023 02:33 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:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Regyna Jackson-Brandcomb, AdministratorTIME COMPLETED:
02:45 PM
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On 9/21/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Regyna Jackson-Brandcomb. The facility currently provides care for 3 clients, all of which were attending day program at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 7/5/2023. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured at 111.8 degrees F which is within Title 22 Regulations. LPA observed facility restroom flooring to have minor water damage and in need of repair. There is no indication of hazard or risk of slipping based on observation. The facility has already contacted maintenance manager who has quoted the repairs and scheduled to return by 9/27/2023 for completion. LPA also observed the garage door handle on the inside of the facility and a single fence panel in the side yard both in need of replacement. Technical Violation issued for follow up on repairs.

Facility conducts and records emergency disaster drills on a monthly basis. Medications are located in a designated cabinet located in the hallway and found to be secured. A spot medication count was conducted for clients and found to be in order along with properly documented centrally stored medication records. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed all client records and found all documents including Needs & Service Plan, North Bay Regional Center Individual Program Plans and Physician's Reports to be current. All clients attending day program are currently provided transport to and from the facility directly from the day programs. There is a sufficient supply of linens, hygiene product and paper products available for client use. Client P&I funds were also observed to be secured and not commingled.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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: 09/21/2023
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LPA and Administrator, Regyna Jackson-Brandcomb discussed the current Licensee, Alma Cupid's plan for a facility change of ownership. LPA spoke with both parties and directed them to contact the CCLD Centralized Application's Bureau to initiate the change of ownership process. North Bay Regional Center, clients and client families have also been notified of the plans.

Administrator, Regyna Jackson-Brandcomb's Administrator Certification 6044328735 is currently pending for renewal. LPA confirmed on CCLD Pending Application list that the certification application payment was received as of 5/10/2023.

LPA requested the following documents be sent to CCL by COB 10/21/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership/Control of Property

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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