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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803359
Report Date: 11/16/2021
Date Signed: 11/16/2021 12:05:31 PM

Document Has Been Signed on 11/16/2021 12:05 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 5DATE:
11/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alma CupidTIME COMPLETED:
12:30 PM
NARRATIVE
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During the course of a complaint investigation, Licensing Program Analyst Leibert learned that S1 functions at the facility as "volunteer staff" but has not been criminally cleared and associated with the facility. This information was obtained by statements made to LPA by staff and by S1. A citation is issued today for the purpose of curing this deficiency.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. A civil Penalty in the amount of $100.00 is issued for volunteer not cleared to assist with clients in care.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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Document Has Been Signed on 11/16/2021 12:05 PM - It Cannot Be Edited


Created By: David Leibert On 11/16/2021 at 11:19 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: KELLYS FAMILY CARE
FACILITY NUMBER: 486803359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
80019(e)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption ....*** Based upon statements made by witnesses,
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Licensee to submit verification that S1 has been cleared and associated to facility or submit declaration, dated and signed, stating that S1 will no longer remain at the facility going forward. Submit by POC date in order to clear the deficiency.

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This requirement has not been met as evidenced by: S1 has volunteered at the facility and has not been granted a criminal record clearance. This poses a potential risk to clients in care. Civil penalty issued in the amount of $100.00
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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:Carla Martinez
LICENSING EVALUATOR NAME:David Leibert
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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