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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201131
Report Date: 02/16/2023
Date Signed: 02/16/2023 04:28:12 PM


Document Has Been Signed on 02/16/2023 04:28 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: 5DATE:
02/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Sarvjeet Dhillon, Administrator/Licensee
Sharan Kaur, Administrator/Licensee		TIME COMPLETED:
04:40 PM
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On 2/16/2023 at 3:10PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 2/10/2023. LPA met with Administrators/Licensees, Sharan Kaur and Sarvjeet Dhillon.

Incident report dated 2/10/2023 revealed that R1 left with son on 2/9/2023. R1 went with son voluntary. Police was called later that day and found that R1 and son was at R1's home in Castro Valley.

During visit, LPA interviewed resident and staff. LPA also reviewed R1's file. R1's physician's report dated 1/23/2023 states that R1 can leave the facility unassisted. Interview with S1 revealed that there was no restraining order for R1's son. R1 is not conserved and POA (medical) was the daughter. R1 was returned to the facility with the daughter on 2/14/2023.


No deficiency was cited on this date.


Exit interview conducted. 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: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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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