486803359-9-21-2023-21-AS-DTOA-CVVPE2-20230921111425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803359
Report Date: 09/21/2023
Date Signed: 09/21/2023 11:14:32 AM

Document Has Been Signed on 09/21/2023 11:14 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 CARE		FACILITY NUMBER:	486803359
ADMINISTRATOR:	CUPID, ALMA V.		FACILITY TYPE:	735
ADDRESS:	392 TULIP STREET		TELEPHONE:	(707) 342-3701
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6		CENSUS: 5	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Regyna Jackson-Brandcomb, Administrator		TIME COMPLETED:	11:25 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/21/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Dysha Cupid. The facility Administrator, Regyna Jackson-Brandcomb was contacted and arrived later in the visit. The facility currently provides care for 5 clients, 3 of which were attending day program and 2 of which were present 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 8/26/2023. 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 112.2 degrees F which is within Title 22 Regulations. Shed located in the backyard stores landlords items and was found to be secured. Emergency exit located in the backyard was also found to be unobstructed. Facility conducts and records emergency disaster drills on a monthly basis. Medications are located in a designated cabinet located in the kitchen and found to be secured. A spot medication count was conducted for clients and found to be in order. LPA found that the facility is not consistently receiving printout centrally stored medication records (CSMR) from the pharmacy. LPA recommended for facility to printout blank CSMR form to reconcile prescription information when needed. Technical Assistance issued. 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. 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	FACILITY NUMBER: 486803359
	VISIT DATE: 09/21/2023

NARRATIVE

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All clients attending day program are currently provided transport to and from the facility directly from the day programs. The two clients that were at the facility during the time of visit have been reassessed and awaiting determination for return to their respective day programs.

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

No deficiencies cited

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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