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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200913
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:30:52 PM


Document Has Been Signed on 09/14/2022 04:30 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:KALYNNA HOMEFACILITY NUMBER:
079200913
ADMINISTRATOR:IKHARO, RAUFATFACILITY TYPE:
740
ADDRESS:5366 THUNDERBIRD COURTTELEPHONE:
(925) 303-3853
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 3DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Irene London, Administrator
Kristine Emanuel, Staff		TIME COMPLETED:
05:00 PM
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On 9/14/22 at 3PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with staff (S1) and administrator (ADM) who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit to S1 and ADM. LPA observed one staff wearing face mask and one resident watching TV while the other 2 residents were relaxing inside their bedrooms.

LPA toured the facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. LPA observed 30-day supply of medications stored in locked kitchen cabinets. Sufficient PPEs and paper supplies were stored in the kitchen cabinets. Facility has an emergency plan that includes the infection control plan.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/15/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan including infection control plan
· Evidence of Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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