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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201131
Report Date: 02/25/2022
Date Signed: 02/25/2022 01:01:35 PM


Document Has Been Signed on 02/25/2022 01:01 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:KHIVI CARE, LLCFACILITY NUMBER:
019201131
ADMINISTRATOR:DHILLON, SARVJEETFACILITY TYPE:
740
ADDRESS:994 DESCONSADO AVETELEPHONE:
(925) 250-6843
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 0DATE:
02/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sarvjeet Dhillon, Licensee/Applicant
Sharan Kaur, Licensee/Applicant		TIME COMPLETED:
01:00 PM
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On 2/25/2022 at 9:00AM, Licensing Program Analyst (LPA) G. Luk arrived to conduct a Pre-Licensing inspection. LPA met with Licensee(s)/Applicant(s), Sarvjeet Dhillon and Sharan Kaur. The facility's fire clearance was approved for 1 ambulatory, 4 non-ambulatory, and 1 bedridden residents.

LPA toured facility including but not limited to resident's bedrooms, bathrooms, living room, kitchen, garage, and outdoor area. Resident's rooms were fully furnished and clean. Hot water was measured at 117.6 degrees F in the hallway bathroom sink. LPA observed lighting in all rooms. LPA observed facility had some non-perishable and perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Smoke detectors and carbon monoxide detector were observed in operating condition. First aid kit was complete. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 6/22/2021. Emergency disaster plan was complete.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPA did not observed mattress pads for resident's beds.

2. LPA was informed that the half bathroom was dedicated to staff only because toilet does not have a grab bar. Licensee will put a sign on the door stating it's a staff bathroom.

3. LPA observed a trampoline, a kid's playset, and some wood planks in the backyard. LPA advised that those items needs to be removed.

4. LPA observed that licensee did not have liability insurance.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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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: KHIVI CARE, LLC
FACILITY NUMBER: 019201131
VISIT DATE: 02/25/2022
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Licensee/applicant will submit proof of corrections to CCL on/before 2/28/2022.

LPA conducted Component III with Licensees during inspection. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.

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

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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