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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173008720
Report Date: 11/05/2024
Date Signed: 11/05/2024 11:52:26 AM

Document Has Been Signed on 11/05/2024 11:52 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
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: 5DATE:
11/05/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Michelle McBrayerTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Sebastian Phouthavong made an unannounced Case Management to conduct a quarterly Legal/Non-Compliance visit to the facility and met with Licensee, Michelle McBrayer for the purpose of ensuring compliance with the terms of the Stipulation or Decision and Order; effective on 05/31/2024. The licensee was granted probationary license subject to the following limitations and conditions:

The inspection is being conducted to confirm the continual compliance with the following limitations and conditions:

· Respondent shall operate the facility in strict compliance with the regulations and statutes governing the operation of an FCCH.

· During the period of probation, the Department in its sole discretion may conduct unannounced site visits for the purpose of determining whether there is full compliance with the regulations and statutes governing the operation of a FCCH.

· Respondent is required to maintain an accurate, complete, and current client roster which must be made available to the Department upon request.

· Respondent shall ensure that all documentation provided to the resource and referral agency to receive subsidy program funds is complete and accurate.

· Respondent shall, within ninety (90) days of the adoption of this Stipulation, complete four (4) hours of training related to the personal rights of children. Respondent shall submit proof of completion to the Santa Rosa Child Care Unit at 1450 Neotomas Avenue, Ste. 100, Santa Rosa, CA 95405.

· This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period.

(Continued on LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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: MCBRAYER, MICHELLE FCCH
FACILITY NUMBER: 173008720
VISIT DATE: 11/05/2024
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(Continued from LIC 809)
During the inspection the home was toured inside and outside. The licensee was supervising five children and operating within the licensed capacity and ratio requirements. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire on 07/2026. Five children's records were reviewed at 10:34AM. Facility and personnel files were reviewed and contained required records.

In addition, LPA arrived to deliver an amended report for the initial report issued on 09/20/2024. The amended report includes updated civil penalty language.

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: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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