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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200987
Report Date: 06/10/2022
Date Signed: 06/10/2022 03:15:13 PM

Document Has Been Signed on 06/10/2022 03:15 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:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Warlita, Agmata RivacTIME COMPLETED:
03:20 PM
NARRATIVE
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On 06/10/2022 at 12:00pm, Licensing Program Analyst (LPA) L. Fici & C. Lin arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with back up Administrator (ADM), Agmata Warlita and explained the purpose of the visit.

LPAs toured facility with including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Fire extinguisher was observed serviced 10/22/2021. LPAs observed facility passages inside and out free of obstruction.

Continue on LIC809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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: 06/10/2022
NARRATIVE
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Continued on Lic809C

The following deficiency was observed:
1:00pm- LPAs observed flies coming out from under the sink; approximately 15 flies or more.
1:03pm- LPAs observed 2 knifes and scissors in the kitchen cabinet unlocked and accessible to residents.
1:05pm- LPAs observed cleaning Tide detergent on top of the washer machine in the garage.
1:10pm- LPAs observed R1 with half bed rail, and with no physicians order.
1:25pm- LPAs observed a shed in the back yard where administrator told LPAs S1 sleeps in there.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with ADM Report provided along with appeal rights.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/10/2022 03:15 PM - It Cannot Be Edited


Created By: Liridon Fici On 06/10/2022 at 02:17 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: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia:

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


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 having inaccessible Sharps, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/11/2022
Plan of Correction
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Administrator agreed to re-train staff on regulations and submit an in service training with staff signatures to CCL by POC date.


Administrator locked up knifes and sccissors during visit.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia:

(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 having inaccessible toxins, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/11/2022
Plan of Correction
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Administrator agreed to re-train staff on regulations and submit an in service training with staff signatures to CCL by POC date.


Administrator locked up knifes and sccissors during visit.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


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Document Has Been Signed on 06/10/2022 03:15 PM - It Cannot Be Edited


Created By: Liridon Fici On 06/10/2022 at 02:34 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: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(27)
87555 General Food Service Requirements:

(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 not having the kitchen free of insects, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Administrator agreed to submit a photo copy to CCL by POC date by patching up the crack under the sink so flies will not enter the facility.
Type B
Section Cited
CCR
87305(a)
87305 Alterations to Existing Building or New Facilities:

(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not obtaining a permit for shed located in backyard using to reside staff member which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Licensee agrees to submit a copy of a permit for the shed located in the backyard by POC date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


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Document Has Been Signed on 06/10/2022 03:15 PM - It Cannot Be Edited


Created By: Liridon Fici On 06/10/2022 at 02:44 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: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(5)(A)
87608 Postural Support:

(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having a doctor’s order for half bed rail for R1, Which poses a potential health and safety risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Adminisinstraor agrees to submit a physcians order for half bed rail for R1 to CCL by POC due date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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