019201086-9-14-2021-15-AS-ADEO-C6USEY-20210914134930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201086
Report Date: 09/14/2021
Date Signed: 09/14/2021 01:49:43 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:	K & J RESIDENTIAL CARE HOME-HAYWARD		FACILITY NUMBER:	019201086
ADMINISTRATOR:	LIANG, KSAI		FACILITY TYPE:	740
ADDRESS:	838 W. SUNSET BLVD.		TELEPHONE:	(510) 360-0888
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	6	CENSUS: 0	DATE:	09/14/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ksai Liang/Applicant-Administrator and Elton Brown/Staff		TIME COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection. License application is for six (6) total capacity, all non-ambulatory. Fire clearance was granted on August 13, 2021. LPA met with Ksai Liang, applicant-administrator, and Elton Brown, staff. The facility to be licensed is 1 building/unit. LPA toured the facility inside out with Ksai Liang and Elton Brown. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department; however, there's no perimeter fence. LPA inspected the living room, dining area, kitchen, bedrooms. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed sufficient good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet to store knives and range knobs was observed with lock. Cabinet to be used to centrally store medications was also observed with lock. LPA observed COVID-19 signage all throughout the facility and a central screening table set-up by the entrance door. PPEs are available. Bathrooms/showers were observed equipped with grab bars and non-skid mats. Trash bins were observed step-on with lids. Fire extinguishers were observed fully charge and tags showed serviced June 28, 2021. The two-in-one carbon monoxide and smoke detectors were tested and observed operational. First aid kit inspected and observed complete with manual. Facility has flash lights for emergency lighting. Hot water temperature in one of the bathrooms were tested and measured at 118.4 degrees Fahrenheit. .....continued on 809C (page 2)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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-HAYWARD	FACILITY NUMBER: 019201086
	VISIT DATE: 09/14/2021

NARRATIVE

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Page 2

Complaint poster, personal rights, Rights to Resident Council and Right to Family Council were observed posted in the prominent place in the facility.

LPA observed the following:
1. The facility compound comprises of 4 separate buildings with total 8 units; applicant is applying for facility license for one of the units and the rest of the units are rentals. LPA observed there's no perimeter fence separating the facility from the rest of the rental properties.
2. There's total of five bedrooms for residents' use and each of the bedroom was observed can have maximum of 1 bed only.
3. Theft and Loss Policy not posted.
4. No Ombudsman poster.
5. Cabinets in the laundry room where laundry supplies are to be kept have no locks.
6. There's only 10 disposable gowns.
7. No supplies for residents' activities.
8. No auditory signals on entrance and exit doors and call buttons/bells for residents' use.
9. Elton Brown is not associated to this facility. Applicant stated Elton will be the administrator.

Applicant to do and submit the following by October 14, 2021:
1. Install perimeter fence.
2. Submit LIC200 for 5 total capacity.
3. Submit updated sketches showing the following:
-Exit doors and windows
-Dimensions and use of each room
-Number of resident in each bedroom
-Utility shut off locations
-Outside sketch showing the building and perimeter fence

.....continued on 809C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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-HAYWARD	FACILITY NUMBER: 019201086
	VISIT DATE: 09/14/2021

NARRATIVE

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4. Post Ombudsman poster and Theft and Loss Policy
5. Install locks in the laundry room cabinets
6. Purchase additional disposable gowns
7. Purchase activity supplies
8. Install auditory signal on entrance and exit doors and purchase bells for residents' use.
9. Submit LIC9182 for Elton Brown along with the following:
-Signed letter indicating change in administrator
-Copy of US issued photo ID of Elton Brown
-LIC501 Personnel Record
-Copy of Elton Brown's current administrator certificate

Upon receipt of LIC200 and updated sketches, LPA to submit to Central Application Bureau analyst who in turn will submit a new request for fire safety inspection.

LPA to do re-inspection once the new fire clearance is granted and corrections to the other deficiencies are completed.

Exit interview conducted and copy of this report provided to Ksai Liang.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4