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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200987
Report Date: 06/21/2024
Date Signed: 06/21/2024 12:13:14 PM

Document Has Been Signed on 06/21/2024 12:13 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:K & J RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200987
ADMINISTRATOR/
DIRECTOR:		LIANG, KSAIFACILITY TYPE:
740
ADDRESS:1954 ROSEMARY CT.TELEPHONE:
(510) 396-5818
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 6CENSUS: 5DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:55 AM
MET WITH:Administrator, Warlita Agmata-RivacTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 6/21/2024 at 7:55 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Warlita Agmata-Rivac and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory.

LPA toured facility with Warlita Agmata-Rivac including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 8/11/2023. Emergency Disaster Plan was last posted on 1/1/2024. First aid kit was observed to be complete.

At 8:15am, LPA reviewed 5 residents records. At 11:00am, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.


Report continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: K & J RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200987
VISIT DATE: 06/21/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 8:00am LPA observed a bed set up in the living room that is used by staff to sleep on during the night. Administrator confirmed that the staff sleep on the bed. Also At 9:40am during facility tour LPA observed that in the backyard a shed has been converted and is being occupied by a caregiver. The structure is not cleared on the facility sketch and Administrator confirmed that the shed was converted after the last annual inspection was conducted. (Repeat Violation:87307(a)(2)(B)) $250
  • At 8:30am during file review LPA observed that R2 does not have an Needs and Services Plan. Administrator confirmed they have not done the appraisal. (Repeat Violation: 87506(b)) $250
  • At 8:50am during file review LPA observed that R3's physicians report lists them as BEDRIDDEN. LPA contacted the primary care physician to confirm this diagnosis. Physician confirmed resident is bedridden. Facility is not cleared for bedridden. (Immediate Civil Penalty: 87202(a)(2)) $500
  • At 9:28am during facility tour LPA observed the dishwasher being used as a storage place for dishes. LPA observed a large cooking knife with a yellow handle stored inside. Administrator removed and locked away knife. Also at 9:29am during facility tour LPA observed ZZZQuil unlocked in the bottom kitchen counter. Administrator removed and locked away PRN.
  • At 10:17am LPA contacted desk duty to inquire about the status of the Administrators certificate. There is no certificate application pending. The last certificate expired 12/17/2021.(Repeat Violation:87412(d)) $250
  • At 11:22am during file review LPA did not observe a disaster drill on file. Administrator states they have not done any drills this year.

***An immediate civil penalty is being assessed today for $500 for fire clearance violation 87202(a)(2)***


**A civil penalty is being assessed today for $750 for all other repeat violations {$250 per violation x 3}**
Civil penalty total= $1,250

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. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/21/2024 12:13 PM - It Cannot Be Edited


Created By: Alona Gomez On 06/21/2024 at 11:41 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
, 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: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
87412(d) Personnel Records: (d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

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 in not having a current administrator certificate on file which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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By POC date administrator agrees to submit the required documentation to start the certificate renewal process.
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:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2024 12:13 PM - It Cannot Be Edited


Created By: Alona Gomez On 06/21/2024 at 11:58 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
, 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: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in R2 being bedridden which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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By POC date Administrator agrees to have resident reassesed or come up with a placement plan and notify CCLD.
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 dangerous items unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Administrator removed and secured items.
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:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/21/2024 12:13 PM - It Cannot Be Edited


Created By: Alona Gomez On 06/21/2024 at 11:58 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
, 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: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

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 in having a bed set up in the living room for staff to sleep on which poses a potential personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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By POC date Administrator agrees to remove bed and notify CCLD.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R2 not having a needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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By POC date Administrator agrees to review all residents files to ensure the are complete and up to date and notify CCLD.
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:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/21/2024 12:13 PM - It Cannot Be Edited


Created By: Alona Gomez On 06/21/2024 at 11:58 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
, 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: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited abovenot having done a disaster drill this year which poses a potential safety risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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By POC date administrator agrees to complete and log emergency disaster drill and notify CCLD.
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:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
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