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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201408
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:19:19 PM

Document Has Been Signed on 08/15/2024 02:19 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:KENNET HOME LLCFACILITY NUMBER:
019201408
ADMINISTRATOR/
DIRECTOR:		BIYOK, ELLENFACILITY TYPE:
735
ADDRESS:880 LESTER AVETELEPHONE:
(510) 604-4638
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 0DATE:
08/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Ellen Biyok/Applicant-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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At 11:30 a.m. on this day, August 15, 2024, Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection and met with Ellen Biyok, applicant-administrator. License application is for change of location for six (6) total capacity, of which 2 may be non-ambulatory . Fire clearance was granted on July 22, 2024.

Applicant submitted the LIC610D Emergency Disaster Plan to Central Application Bureau (CAB) analyst; however, corrected copy showing one of the shelter locations in city outside of Hayward obtained by LPA on this day.

LPA toured the facility inside out with applicant-administrator. LPA inspected the living room, kitchen, bedrooms, bathrooms, staff room, front, side and backyard. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels and linens. Supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed adequate for residents' use. There’s 7 days supplies of non-perishables and 2 days of perishables. Facility is equipped with refrigerator, microwave and dishwasher. Central storage for medications, cabinet for cleaning supplies and cabinets for residents and staff files were observed with locks.

First aid kit inspected and observed complete with manual. Fire extinguisher was observed fully charge with tag showed serviced 9/25/23. Facility has carbon monoxide and smoke detectors that were tested and observed functional.

LPA observed the following:
-at 11:30 a.m., front yard with uneven ground surface.
-at 11:35 a.m., fireplace not properly screened.
.....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 2
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: KENNET HOME LLC
FACILITY NUMBER: 019201408
VISIT DATE: 08/15/2024
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-at 11:45 a.m., bathrooms and kitchen with no trash cans.
-at 11:55 a.m., hot water temperature at 121.4 degrees Fahrenheit.
-at 12:00 p.m., toilets with no grab bars.
-at 12:05 p.m, no washer and dryer. Applicant-administrator to transfer the washer and dryer from the current licensed facility to this location once licensed is granted.
-at 12:07 p.m., elevated part of the ground surface in the backyard.
-at 12:08 p.m., bricks in the backyard and side yard.

Facility does not have telephone service as of this day. Applicant-administrator stated there's already a job order that once license is granted for this location, the telephone service from the current licensed facility will be transferred to this location. Applicant-administrator agreed and stated she'll submit to LPA copy of self-certification and job order by August 22, 2024.

On this same day, LPA obtained copy of corrected and signed copy of LIC9282 Infection Control Plan

Applicant-administrator stated she'll submit proof of corrections for the following by August 22, 2024:
-picture of front yard showing ground is even out.
-picture of fireplace showing screen is properly secured.
-proof of purchase for trash cans with touch free lids.
-picture showing hot water temperature adjusted within Regulations range.
-pictures showing grab bars installed in the toilets.
-self-certification stating washer and dryer will be transferred to this facility once license is granted.
-paint yellow strips on the edge of the elevated surface in the backyard.
-pictures showing bricks were removed.

LPA will inform CAB analyst when POCS are received. Upon final review of application, license to be granted by CAB analyst.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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