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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200913
Report Date: 02/13/2025
Date Signed: 02/13/2025 02:43:09 PM

Document Has Been Signed on 02/13/2025 02:43 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/
DIRECTOR:		IKHARO, RAUFATFACILITY TYPE:
740
ADDRESS:5366 THUNDERBIRD COURTTELEPHONE:
(925) 303-3853
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/13/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:23 PM
MET WITH:Raufat Ikharo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 02/13/25 at 2:23PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check due to the department receiving a priority 2 complaint.

During the health and safety check, LPA observed a total of 2 staff members and 5 residents at the facility. LPA toured facility, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
Bennett FongTELEPHONE: (510) 622-2621
Daisy PanlilioTELEPHONE: (510) 286-4201
DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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