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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201086
Report Date: 02/26/2025
Date Signed: 02/26/2025 05:15:14 PM

Document Has Been Signed on 02/26/2025 05:15 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:K & J RESIDENTIAL CARE HOME-HAYWARDFACILITY NUMBER:
019201086
ADMINISTRATOR/
DIRECTOR:		BROWN, ELTONFACILITY TYPE:
740
ADDRESS:838 W. SUNSET BLVD.TELEPHONE:
(510) 363-9387
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 5CENSUS: 4DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Elton Brown/Administrator and
Ester Ramirez/Assistant Administrator 		TIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On this day, February 26, 2025, at 12:50 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Caprisha Twine, and informed the reason for visit. LPA called and spoke over the phone with Elton Brown, administrator (ADM). ADM arrived at around 1:05 pm followed by Ester Ramirez, assistant administrator (AADM).

LPA started the inspection with Caprisha Twine and continued with ADM and AADM. LPA inspected the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has 2 in 1 smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 115 degrees Fahrenheit. Facility conducts disaster drills at least every quarter and records showed last conducted 12/03/24.

LPA reviewed 4 residents and 4 staff files. Residents medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.

LPA observed the following:
-at 1:01 pm, rotten lettuce, zucchini with mold, expired bacon bits (expiration: 2022) and parmesan cheese (expiration: 2022).
-at 1:10 pm, paint in the backyard.
-at 1:18 pm, peritoneal cleanser, Cortizone ointment in a closet without lock.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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: 02/26/2025
NARRATIVE
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-at 3:50 pm, 2 of resident's (R1) medications not recorded on LIC622.

Administrator to submit updated/current copies of the following by March 12, 2025:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Proof of $3M liability insurance

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with ADM and AADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/26/2025 05:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/26/2025 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: K & J RESIDENTIAL CARE HOME-HAYWARD
FACILITY NUMBER: 019201086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 in the following which pose an immediate health and/or personal rights risk to persons in care: :rotten lettuce, zucchini with mold, expired bacon bits and parmesan cheese.
POC Due Date: 02/27/2025
Plan of Correction
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Staff discarded the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 2/27/25.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/26/2025 05:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/26/2025 at 04:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: K & J RESIDENTIAL CARE HOME-HAYWARD
FACILITY NUMBER: 019201086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not recording R1's medications on LIC622 which poses a potential personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Administrator to have medications recorded and submit proof by 3/12/25.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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