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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600811
Report Date: 01/14/2022
Date Signed: 01/14/2022 01:52:09 PM

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:KENNEDY GUEST HOMEFACILITY NUMBER:
015600811
ADMINISTRATOR:JOYCELYN SILLAFACILITY TYPE:
740
ADDRESS:2636 KENNEDY STREETTELEPHONE:
(925) 449-0145
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 4DATE:
01/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joycelyn Silla, AdministratorTIME COMPLETED:
02:05 PM
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On 1/14/2022 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Joycelyn Silla.

Upon entry, LPA's temperature was checked and asked to fill out visitor's log. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. All hand washing stations were equipped with soap and paper towel.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food supplies and paper supplies are sufficient.

No deficiencies cited on this date.

Exit interview conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
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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