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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201381
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:01:50 PM

Document Has Been Signed on 10/28/2024 02:01 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:KINGDOM BUILDERS TRANSITIONAL HOUSING PROGRAMFACILITY NUMBER:
019201381
ADMINISTRATOR/
DIRECTOR:		JENNINGS, KARENFACILITY TYPE:
772
ADDRESS:432 CLARA STREETTELEPHONE:
(510) 575-9881
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 6CENSUS: 0DATE:
10/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:LJ Jennings, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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On this date, October 28, 2024, Licensing Program Analyst (LPA) K. Nguyen conducted a pre-licensing inspection, and met with LJ Jennings, applicant. License application is for six (6) total capacity all are 6 are ambulatory. Fire clearance was granted on June 27, 2024.

LPA toured the facility with the applicant. Physical plant is consistent with the facility sketches submitted to Centralized Application Bureau (CAB). There is no body of water. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Supplies of towels, bed sheets, linens were adequate. Equipment and supplies for residents' personal hygiene were available and on site. Food supplies were observed adequate for seven days of non-perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Storage where knives and medications will be centrally stored was observed with lock. Complaint and Personal Rights posters were observed posted in prominent place. Facility land line telephone was tested and observed operational.

Fire extinguisher checked, observed fully charge with tag showed serviced January 23, 2024. First aid kit checked and observed complete with manual. Hot water temperature was tested in one of the common bathrooms and measured at 100.3 degrees Fahrenheit. Carbon monoxide and smoke detectors were tested and observed operational.

LPA will inform CAB that this license is ready to be license.

COMP III conducted.

Exit interview conducted with LJ Jennings and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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