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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173008720
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:34:09 PM

Document Has Been Signed on 09/26/2024 12:34 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:MCBRAYER, MICHELLE FCCHFACILITY NUMBER:
173008720
ADMINISTRATOR/
DIRECTOR:		MCBRAYER, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 994-9580
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Mchelle McBrayerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 09/26/2024 at 11:30AM, Licensing Program Analyst, Sebastian Phouthavong made an unannounced Case Management visit to the facility and met with Licensee, Michelle McBrayer today to verify operation at the facility, and to address the facility's Plan of Correction. Prior to visit, on 09/20/2024, the facility was cited a Type A deficiency.

During the visit, LPA observed four children receiving care by Licensee and two assistants. LPA did not observe a Pet Play Pen for the Licensee’s dog as part the Facility’s Plan of Correction. But Licensee stated she has already ordered a Pet Play Pen and will arrived soon. LPA reviewed signed Acknowledgement of Receipt of Licensing Report (LIC 9224) from the facility. Licensee submitted an updated plan regarding the dog for when the FCCH is operational.

Exit interview conducted and report was reviewed with the licensee, Michelle McBrayer. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The were no violation(s) of the California Code of Regulations, Title 22; Division 12 cited during today’s visit.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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