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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200337
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:07:11 PM

Document Has Been Signed on 01/27/2023 03:07 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:KARYDOM INC.FACILITY NUMBER:
079200337
ADMINISTRATOR:MAUREEN PALMFACILITY TYPE:
735
ADDRESS:2386 GLENDALE CIRCLETELEPHONE:
(925) 778-1506
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 4DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Funmilayo "Emily" Olabinke, CaregiverTIME COMPLETED:
03:15 PM
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On 01/27/2023 at 1:50PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Funmilayo "Emily" Olabinke, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Maureen Palm via telephone and approval was given for Caregiver to sign documents.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 118.5 degrees Fahrenheit. Fire extinguisher last serviced on 1/31/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke/carbon monoxide detector operable.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the infection control plan on file. LPA observed PPE and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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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: KARYDOM INC.
FACILITY NUMBER: 079200337
VISIT DATE: 01/27/2023
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 2/3/2023:
  • Emergency Disaster Plan (LIC610D)
  • Personnel Record (LIC500)
  • Administrator certificate
  • Updated facility sketch.


No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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