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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201086
Report Date: 09/14/2021
Date Signed: 09/14/2021 04:31:24 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-HAYWARDFACILITY NUMBER:
019201086
ADMINISTRATOR:LIANG, KSAIFACILITY TYPE:
740
ADDRESS:838 W. SUNSET BLVD.TELEPHONE:
(510) 360-0888
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 0DATE:
09/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Ksai Liang/Applicant-Administrator
and Elton Brown/Staff		TIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Delmundo conducted an announced Component III Training via Teams Meeting. Component III was attended by Ksai Liang, applicant-administrator and Elton Brown, staff.

LPA Delmundo presented the training via Power Point presentation and had a discussion with Ksai Liang and Elton Brown.

Exit interview conducted and copy of this report provided to Ksai Liang at the conclusion of the training.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (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)
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