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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600811
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:19:12 AM


Document Has Been Signed on 01/27/2023 11:19 AM - 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:KENNEDY GUEST HOMEFACILITY NUMBER:
015600811
ADMINISTRATOR:JOYCELYN SILLAFACILITY TYPE:
740
ADDRESS:2636 KENNEDY STREETTELEPHONE:
(925) 449-0145
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 3DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Joycelyn Silla, AdministratorTIME COMPLETED:
11:30 AM
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On 1/27/2023 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPAs 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, garage, and outdoor areas. All sinks were equipped with soap and paper towel. Hot water was measured at 120 degrees F in the hallway bathroom. Fire extinguisher was observed to be full and last serviced on 12/7/2022.

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

At 9:25AM, LPA observed unlocked paints and gardening tools in the backyard. Staff locked up the paints and gardening tools during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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Document Has Been Signed on 01/27/2023 11:19 AM - It Cannot Be Edited

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: KENNEDY GUEST HOME
FACILITY NUMBER: 015600811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlocked paints and gardening tool which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/28/2023
Plan of Correction
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Staff locked up the paints and gardening tools during inspection.

Deficiency cleared.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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