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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803359
Report Date: 08/02/2022
Date Signed: 08/02/2022 11:18:40 AM

Document Has Been Signed on 08/02/2022 11:18 AM - 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 CAREFACILITY NUMBER:
486803359
ADMINISTRATOR:CUPID, ALMA V.FACILITY TYPE:
735
ADDRESS:392 TULIP STREETTELEPHONE:
(707) 342-3701
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
08/02/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Staff Member, Dysha CupidTIME COMPLETED:
11:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Kellys Family Care for the purpose of conducting a Plan of Correction (POC) inspection. LPA met with Staff Member, Dysha Cupid, and was granted access into the facility.

The POC inspection was due to a deficiency that was cited on July 22, 2022. During the POC inspection, LPA inspected both bathrooms and found that the hot water temperature measured at 116.7 degrees F and is within regulation.

No deficiencies were observed or cited during today's POC inspection. Exit interview was conducted and a copy of this report was signed and given to the Staff Member, Dysha Cupid.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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