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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803298
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:08:28 PM

Document Has Been Signed on 09/17/2024 02:08 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KELLYS FAMILY CARE #2FACILITY NUMBER:
486803298
ADMINISTRATOR/
DIRECTOR:		CUPID, ALMAFACILITY TYPE:
735
ADDRESS:2504 SUNRISE DRIVETELEPHONE:
(707) 421-2950
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 3DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Staff Member, Debra Jackson and Administrator, Regyna Jackson-BrandcombTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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At approximately 12:20PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Debra Jackson. Administrator, Regyna Jackson-Brandcomb, arrived at approximately 12:40PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 5 Ambulatory Clients. Upon arrival, LPA was informed that there were 3 clients in care with all 3 clients out of the facility attending Day Program. LPA was also informed that there was one staff member on-site.

At approximately 12:30PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 12:45PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 3 Client bedrooms, 1 staff room, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected August 2024. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire/disaster drill was conducted in August 2024.

At approximately 1:00PM, LPA reviewed staff files, client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. P&I monies were documented, secure and not commingled. Administrator's Certificate for Regyna Jackson-Brandcomb (6044328735) current with expiration date of 05/04/2025.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KELLYS FAMILY CARE #2
FACILITY NUMBER: 486803298
VISIT DATE: 09/17/2024
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Continued from LIC809

LPA and Administrator discussed change of ownership plans. During visit conducted on 09/21/2023, Community Care Licensing (CCL) was informed of the Licensee's intent to do a change of ownership to the current Administrator. Per Administrator, change of ownership will still be occurring. Application to be submitted.

LPA requested the following documents to update facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of 10/17/2024.

No Deficiencies Cited during Visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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