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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201131
Report Date: 03/05/2025
Date Signed: 03/05/2025 04:10:15 PM

Document Has Been Signed on 03/05/2025 04:10 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:KHIVI CARE, LLCFACILITY NUMBER:
019201131
ADMINISTRATOR/
DIRECTOR:
DHILLON, SARVJEETFACILITY TYPE:
740
ADDRESS:994 DESCONSADO AVETELEPHONE:
(925) 250-6843
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Sarvjeet Dhillon and Sharan Kaur, AdministratorsTIME VISIT/
INSPECTION COMPLETED:
04:22 PM
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On 3/5/2025 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrators, Sarvjeet Dhillon and Sharan Kaur. Facility's fire clearance was approved for 5 non-ambulatory residents and 1 bedridden resident in which 2 residents can be on hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, living room, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 8/22/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 106.1 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete.

LPA reviewed 5 residents and 5 staff files starting at 11:15AM. Residents files were complete with medical assessment, admission agreement, appraisal needs & service plan, etc. All staff are fingerprint cleared and associated to the facility. Staff files were complete and training information was available. LPA reviewed a sample of resident's medications during inspection.

No deficiencies are being cited on this date. However, facility was given technical violation and technical assistance.

Exit interview conducted with Sharan Kaur. A copy of this report, technical violation, and technical assistance were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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