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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010786
Report Date: 03/26/2025
Date Signed: 03/26/2025 10:37:37 AM

Document Has Been Signed on 03/26/2025 10:37 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:
173010786
ADMINISTRATOR/
DIRECTOR:		MICHELLE MCBRAYERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 350-5345
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
03/26/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Michelle McBrayerTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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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 and under the Licensee's previous license number: 173008720. 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)

NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2025
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: 173010786
VISIT DATE: 03/26/2025
NARRATIVE
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Continued from LIC 809)
During the inspection the home was toured inside and outside. The licensee was supervising one child and operating within the licensed capacity and ratio requirements. The facility’s operating hours are Monday - Sunday, 6:00 AM - 11:59 PM. The floor plan submitted by the licensee was reviewed and verified. The children will have access to tv room, playroom, kitchen, dining room, living room and one of the hallway bathrooms. The off-limits areas includes the laundry room, master bedroom with bathroom, the other hallway bathroom, garage and entire 2nd floor including 2 bedrooms and backyard. The off-limits areas of the home will be inaccessible by door locks, plastic doorknob covers and/or child gates. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. The facility was currently under construction and Licensee was reminded to ensure Items which could pose a danger to children are inaccessible at all times. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire on 07/2026. Three children's records were reviewed at 09:19AM. Facility and personnel files were reviewed and contained required records.

Additionally, the facility's backyard pool was observed and have met fencing requirements. The facility was also observed to have a pool alarm that compliant with ASTM International Standard F2208, but was not installed/placed in the pool, not fully meeting Pool Safely Requirements.

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 following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2025 10:37 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 03/26/2025 at 10:01 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: MCBRAYER, MICHELLE FCCH
FACILITY NUMBER: 173010786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2025
Section Cited
HSC
1596.814

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1596.814(a)(1)(B)(ii)(I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use. This requirement is not met as evidenced by:
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Licensee stated she will install the pool alram and submit photos/videos of the alarm in use to the department by 04/09/2025
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Based on LPA's observaton, the facility's pool alarm was not currently installed and placed in the facility swimming pool. which poses a potential health, safety, or personal rights risk to persons 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.
SUPERVISOR'S NAME:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
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