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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201408
Report Date: 08/22/2025
Date Signed: 08/22/2025 07:05:00 PM

Document Has Been Signed on 08/22/2025 07:05 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) 605-5104
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
08/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Ellen Biyok/Administrator TIME VISIT/
INSPECTION COMPLETED:
07:10 PM
NARRATIVE
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On this day, 8/22/25, at 12:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Thomas Roller and Losanta Jaca, and informed the reason for visit. Losanta Jaca called and spoke with Ellen Biyok, administrator (ADM) over the phone. ADM arrived at around 12.45 pm. LPA also met with other staff, Zenaida Alonzo.

LPA started the inspection with Losanta Jaca and continued with ADM. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced September 18, 2024. Facility has carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in the common bathroom was tested and measured at 111.5 degrees Fahrenheit. Facility conducts disaster drills and records showed last conducted July 4, 2025. Central storage for medications and cleaning supplies were observed locked.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 residents. P&I money checked and compared with last recorded balance. Medications were inspected and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders on file.


...continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: KENNET HOME LLC
FACILITY NUMBER: 019201408
VISIT DATE: 08/22/2025
NARRATIVE
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LPA observed the following:
-at 12:15 pm, medication (1 tablet) in the kitchen counter. LPA checked all the residents' medications and this medication is R1's to be administered in the morning per doctor's order.
-at 12:29 pm, all of residents' medications to be administered the following day were pre-poured.
-at 12:38 pm, staff's cough medications in unlocked cabinet by the hallway.
-at 12:39 pm, medications, Isopropyl alcohol, Ca-Rezz peritoneal cleanser, Vicks VapoRub, disinfectant spray in unlocked staff's room.
-at 12:41 pm, scissors in a drawer without lock.
-at 3:30 pm, staff (S2) have not completed the required on-the-job training.
-at 4:00 pm, resident (R2) does not have LIC9172 Functional Capability Assessment on file.
-at 4:30 pm, resident (R3) does not have Admission Agreement, Pre-Admission Appraisal and LIC9172 on file.
-at 5:00 pm, R3 does not have doctor's order for 1 of the medications and dates medications started not recorded on LIC622 Centrally Stored Medication and Destruction Record.
-at 5:15 pm, quantities of resident's (R4) five medications in the labels do not match the actual quantities received by the facility.

Administrator to submit copies of the following current/updated documents by September 5, 2025:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

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 penalties.

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

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

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/22/2025 07:05 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/22/2025 at 05:54 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: KENNET HOME LLC
FACILITY NUMBER: 019201408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: staff's cough medications in unlocked cabinet; medications, Isopropyl alcohol, Ca-Rezz peritoneal cleanser, Vicks VapoRub, disinfectant spray in unlocked staff's room; scissors in a drawer without lock.
POC Due Date: 08/23/2025
Plan of Correction
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2
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Administrator locked all the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/23/25.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation and record review, the licensee did not comply with the section cited above in R1 not properly assisted with medication adminstration. LPA observed 1 of R1's medication to be administered in the morning was in the kitchen counter which posed an immediate health and/or personal rights risks to persons in care.
POC Due Date: 08/23/2025
Plan of Correction
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Administrator administered medication and destructed the contaminated tablet.
In addition, administrator in-service the staff and submit copy of training topic with attendees signatures by 8/23/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/22/2025 07:05 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/22/2025 at 05:54 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: KENNET HOME LLC
FACILITY NUMBER: 019201408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, tthe licensee did not comply with the section cited above in one of R3's medications not having doctor's order which poses an immediate health and/or personal rights risks to person in care.
POC Due Date: 08/23/2025
Plan of Correction
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Corrected.
Administrator obtained copy of doctor's order while LPA was at the facility.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/22/2025 07:05 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/22/2025 at 05:54 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: KENNET HOME LLC
FACILITY NUMBER: 019201408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in R2 and R3 not having LIC9172 which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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2
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Administrator to complete the LIC9172 and submit copies by 9/05/25.
Type B
Section Cited
CCR
80075(k)(3)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in quantities in the labels of resident's (R4) five medications do not match the actual quantities received by the facility which pose a potential health and/or personal rights risks to person in care.
POC Due Date: 09/05/2025
Plan of Correction
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2
3
4
Administrator to obtain correct labels and submit proof by 9/05/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/22/2025 07:05 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/22/2025 at 05:54 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: KENNET HOME LLC
FACILITY NUMBER: 019201408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in all of residents' medications to be administered the following day were pre-poured which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 09/06/2025
Plan of Correction
1
2
3
4
Administrator to do the following and submit proof by 9/06/25:
1. Have the staff stop pre-pouring the medications.
2. In-service the staff.
Type B
Section Cited
CCR
80068(a)
80068 Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in resident (R3) not having Admission Agreement on file which poses a potential personal rights risk to person in care.
POC Due Date: 09/05/2025
Plan of Correction
1
2
3
4
Administrator to have document completed and submit copy by 9/05/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2025 07:05 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/22/2025 at 06:28 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: KENNET HOME LLC
FACILITY NUMBER: 019201408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.1(b)
85068.1 Admission Procedures
(b) No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in resident (R3) not having Pre-Admission Appraisal on file which poses a potential health, safety and/or personal rights risks to person in care.
POC Due Date: 09/05/2025
Plan of Correction
1
2
3
4
Administrator to complete the document and submit self-certification by 9/05/25.
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in dates R3’s medications started not recorded on LIC622 Centrally Stored Medication and Destruction Record which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
1
2
3
4
Administrator to complete the document and submit self-certification by 9/05/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 08/22/2025 07:05 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/22/2025 at 06:36 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: KENNET HOME LLC
FACILITY NUMBER: 019201408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
80065 Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in staff (S2) not having the complete required on-the-job training which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
1
2
3
4
Administrator to have the staff complete the training and submit proof by 9/05/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
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