486803359-9-17-2024-21-AS-CFES-D97QED-20240917120610

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803359
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:06:18 PM

Document Has Been Signed on 09/17/2024 12:06 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		FACILITY NUMBER:	486803359
ADMINISTRATOR/ DIRECTOR:	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:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Administrator, Regyna Jackson-Brandcomb		TIME VISIT/ INSPECTION COMPLETED:	12:10 PM

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	At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Dysha Cupid. Administrator, Regyna Jackson-Brandcomb, arrived at approximately 9:45AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 5 clients in care with 3 clients out of the facility attending Day Program. LPA was also informed that there was one staff member on-site. At approximately 9:40AM, 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 9:50AM, 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 found to be out of compliance within Title 22 regulations measuring at 102.3F, 104.3F, and 103.2F (See LIC809D, Regulation 80088(e)(1)). LPA observed Administrator raise water heater temperature during visit. LPA and Administrator discussed keeping a water temperature log for documentation. 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 July 2024. At approximately 10:30AM, 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	FACILITY NUMBER: 486803359
	VISIT DATE: 09/17/2024

NARRATIVE

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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.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights 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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Document Has Been Signed on 09/17/2024 12:06 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 09/17/2024 at 11:41 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KELLYS FAMILY CARE	FACILITY NUMBER: 486803359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. LPA observed that the sinks in the facility measured at 102.3F, 104.3F, and 103.2F. LPA observed Administrator raise the water heater temperature during visit. This poses a potential health, safety, and personal rights risk to clients in care.
	POC Due Date: 09/29/2024
	Plan of Correction
1 2 3 4	Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day starting 09/18/2024. Log to include time when water was checked. Log to be submitted to CCL for review and approval by POC due date of 09/29/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Victoria Bertozzi

LICENSING EVALUATOR NAME:

Caitlynn Felias

LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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