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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 173008720
Report Date: 04/14/2023
Date Signed: 04/14/2023 10:31:13 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2023 and conducted by Evaluator Sebastian Phouthavong
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20230111145859
FACILITY NAME:MCBRAYER, MICHELLE FCCHFACILITY NUMBER:
173008720
ADMINISTRATOR:MCBRAYER, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 994-9580
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:14CENSUS: 4DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle McbrayerTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee is submitting fraudulent documents to subsidy program
INVESTIGATION FINDINGS:
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A subsequent complaint investigation visit was made today by Licensing Program Analyst (LPA), Sebastian Phouthavong who met with Licensee, Michelle McBrayer for the purpose of delivering complaint investigation findings for the above allegation. LPA, previously met with Licensee on 01/19/2023 and 03/27/2023 to initiate the investigation by discussing the allegation, conducting interview(s), making observations, and requesting documents.

It is alleged that Licensee was submitting fraudulent documents to the subsidy program agency by submitting required forms certifying day care children were in attendance on dates when they were not actually present in the facility. Licensee amitted to allegation and stated it was a mistake but did confirm that she only had three children in care on one of the dates in question on December 28, 2022. At today’s inspection, the facility was toured inside and out. There were four children being supervised by Licensee at the facility during the time.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 01-CC-20230111145859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MCBRAYER, MICHELLE FCCH
FACILITY NUMBER: 173008720
VISIT DATE: 04/14/2023
NARRATIVE
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Continued from LIC 9099

During the course of the investigation, LPAs conducted interviews with the Licensee, three staff, one adult, and four parents and reviewed records. To qualify for the Subsidized Payment Program, a Licensee is obligated to maintain accurate records to verify children’s attendance for the child care and food services being provided. According to facility inspection report for McBrayer, Michelle FCCH dated 12/28/2022, LPA Phouthavong, was at this facility from 12:00 pm to 1:40 pm, at which time a total of three children were observed in care and counted in the current census which is shown as “Census: 3” on the information section of the facility report. According to the documents obtained, Licensee certified under penalty of perjury by signing each attendance sheet that ten children were receiving care on 12/28/2022. An additional statement (S3) further indicated that only one child was in care on Saturday, 12/3/22, and the facility was not open on Sunday,12/4/22, but attendance records show 10 children signed in on 12/3/22 and six signed in on 12/4/22.

In addition, multiple statements, including A1-A2, indicated that the Licensee would have parents sign a blank sign in/out attendance sheet and Licensee would complete it throughout the month without having parents verify or initial the time. One individual observed the Licensee changing one child’s attendance from half to full day on the sign in sheets for the food program even through the child was present for only half the day.

Furthermore, records obtained by Community Care licensing outlined Serious Deficiency Determination of this facility on January 4, 2023 and January 25, 2023 for “Falsification of Documentation”, Willful Misrepresentation”, and “Lack of Business Integrity”. These findings are based on a review of records which reflect the Licensee entered times in and out on the monthly records when children were found not to be in attendance.

Based on the information gathered during this investigation, the preponderance of evidence standard has been met and therefore, the allegation is determined to be substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and this report was read and discussed with the facility’s licensee, Michelle McBrayer. The Notice of Site Visit shall be posted for 30 days.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 01-CC-20230111145859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MCBRAYER, MICHELLE FCCH
FACILITY NUMBER: 173008720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2023
Section Cited
HSC
1596.885(c)
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1596.885(c) Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state
This requirement was not met as evidenced by:
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Licensee stated she will create a procedure to ensure all documents are accurately submitted and train all staff on the procedure. Within 24 hours, Licensee will submit the procedure to Licensing Program Analyst, Sebastian Phouthavong by either email sebastian.phouthavong@dss.cs.gov or text message
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Based on Licensee submitted fraudulent documents to receive subsidy program funds by showing inaccurate time in and out entries on monthly records when children were found not to be in attendance, which poses an immediate health and safety risk to the children in care.
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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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2023 and conducted by Evaluator Sebastian Phouthavong
COMPLAINT CONTROL NUMBER: 01-CC-20230111145859

FACILITY NAME:MCBRAYER, MICHELLE FCCHFACILITY NUMBER:
173008720
ADMINISTRATOR:MCBRAYER, MICHELLEFACILITY TYPE:
810
ADDRESS:13731 LAKESHORETELEPHONE:
(707) 994-9580
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:14CENSUS: 4DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle McbrayerTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility failed to stay within ratio and/or capacity requirements
INVESTIGATION FINDINGS:
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A subsequent complaint investigation visit was made today by Licensing Program Analyst (LPA), Sebastian Phouthavong who met with Licensee, Michelle McBrayer for the purpose of delivering complaint investigation findings for the above allegation. LPA, previously met with Licensee on 01/19/2023 and 03/27/2023 to initiate the investigation by discussing the allegation, conducting interview(s), making observations, and requesting documents.

Regulation requires a facility to have two care providers when the capacity is above eight children in care and not to exceed the licensed capacity of 14. It is alleged that the facility failed to stay within the ratio and/or capacity requirements, specifically, that when Licensee is not on the premise, two assistants are not always present when there are more than eight children in care. Licensee denied the allegation. At today’s inspection, the facility was toured inside and out. There were four children being supervised by Licensee at the facility during the time.
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 01-CC-20230111145859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MCBRAYER, MICHELLE FCCH
FACILITY NUMBER: 173008720
VISIT DATE: 04/14/2023
NARRATIVE
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Continued from LIC 9099-A
During the course of the investigation, LPAs conducted interviews with the Licensee, three staff, two adults, and four parents and reviewed records. Licensee and staff members (S1-S4) stated when the Licensee is gone from the home, there are at least two substitute staff members presented at the home when the capacity is over eight daycare children. Statements from Licensee and S3 indicated that when the Licensee was gone from the time frame of 12/01/2022 to 12/05/2022 and 01/26/2023 to 01/29/2023, two staff members were providing care during the times when the facility was open, with at least one staff member having a current Pediatric CPR and First Aid Certification. One Adult (A2) statement indicated that at times there was only one staff on the premises, but records could not confirm whether or not two staff were required at those specific times or if the capacity was over eight children. Parent interviews stated to observe at least two staff members providing care at one time, with two interviews stating that there were moments when only one staff member was present with children but could not remember the number of children present. Parents did not have a concern with the capacity at this time.

A1 stated to observe the facility operating out of ratio many years ago, on multiple occasions, one staff member would be left alone with the daycare children while over capacity, but this could not be corroborated.
Based on the information gathered during this investigation, there is no conclusive evidence to show that the Licensee was out of ratio or over capacity. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation. The allegation is determined to be unsubstantiated. There were no Title 22 deficiencies cited. This report was reviewed and discussed with the facility’s Licensee, Michelle McBrayer. Appeal rights were provided. Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5