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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200987
Report Date: 06/22/2021
Date Signed: 06/22/2021 04:29:42 PM

Document Has Been Signed on 06/22/2021 04:29 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:K & J RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200987
ADMINISTRATOR:LIANG, KSAIFACILITY TYPE:
740
ADDRESS:1954 ROSEMARY CT.TELEPHONE:
(510) 396-5818
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 6CENSUS: 6DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Warlita Agmata-Rivac/House Manager
and Ksai liang/Licensee-administrator		TIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Warlita Agmata-Rivac. LPA called and spoke with Ksai Liang, licensee-administrator. LPA informed both Warlita and Ksai the purpose of LPA's visit. LPA asked and Ksai, authorized Warlita to be with LPA during inspection. LPA also met with other staff, Merlyn Agustina Lie. Ksai arrived after about 3 hours.

LPA toured the facility inside and out with Warlita. LPA inspected the resident rooms, bathrooms, kitchen, living room, dining area, side and backyards. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 30 days. Perishable and non-perishable food supplies were observed sufficient.

Fire extinguisher checked, observed fully charge, and tag showed serviced July 17, 2020.

LPA observed the following:
1. Merlyn is not fingerprint cleared. Documents obtained from Warlita showed Merlyn started working June 2, 2021 which LPA confirmed with Warlita and Merlyn.
2. Personal protective equipments (PPEs) such as disposable gowns and N95 mask not sufficient for 30 days.
3. There's no hand washing poster in the kitchen, and droplet pre-cautions and cough etiquette posters anywhere in prominent place in the facility. There's also no updated visitor's poster in the front door.
4. Trash bins in the all 3 bathrooms with no lids.
5. Visitors' temperature not checked.

.....continued next page (809C)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: K & J RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200987
VISIT DATE: 06/22/2021
NARRATIVE
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The following updated documents need to be submitted by July 6, 2021:
1. LIC500 Personnel Report
2. LIC610E Emergency Disaster Plan
3. Proof of $3M liability insurance coverage

Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). A $500.00 civil penalty is assessed on this day. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result additional civil penalties.

Deficiencies and plan and proof of correction were discussed with Ksai Liang.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/22/2021 04:29 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/22/2021 at 02:10 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: K & J RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Merlyn Agustina Lie is not fingerprint cleared and has been working since June 2, 2021 which poses an immediate health and saffety risks to persons in care.
A $500.00 civil penalty is assessed on this day.
POC Due Date: 06/23/2021
Plan of Correction
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Staff left while LPA is at the facility.
Licensee stated she called the Livescan location for fingerprint appointment which is scheduled for tomorrow.
Licensee not to allow staff to work until cleared and associated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2021 04:29 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/22/2021 at 03:55 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: K & J RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out 3 trash bins with no lids which pose a potential health and safety risks to persons in care.
POC Due Date: 07/06/2021
Plan of Correction
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Licensee to purchase trash bins with lids abnd proof of purchase and pcitures by July 6, 2021.
Type B
Section Cited
CCR
87303(a)
87307 Personal Accommodations and Services:
(a) Living accommodations and grounds shall be related to the facility's function.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Part of the living room room is use as sleeping quarter by staff. LPA observed a bed in this area which LPA confirmed upon interview that a staff use it as a sleeping quarter which poses a potential personal rights risk to persons in care.
POC Due Date: 07/06/2021
Plan of Correction
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Licensee to remove the bed. Picture to be submitted by 7/06/2021.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021


LIC809 (FAS) - (06/04)
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