019200987-6-30-2023-15-AS-LFII-CTAU3G-20230630151330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200987
Report Date: 06/30/2023
Date Signed: 06/30/2023 03:13:42 PM

Document Has Been Signed on 06/30/2023 03:13 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:	K & J RESIDENTIAL CARE HOME		FACILITY NUMBER:	019200987
ADMINISTRATOR:	LIANG, KSAI		FACILITY TYPE:	740
ADDRESS:	1954 ROSEMARY CT.		TELEPHONE:	(510) 396-5818
CITY:	FREMONT	STATE: CA	ZIP CODE:	94539
CAPACITY:	6	CENSUS: 4	DATE:	06/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Warlita Agmata-Rivac, Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/30/2023 starting at 10:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Warlita Agmata-Rivac, Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6007524740) expired on 12/17/2021. The facility’s fire clearance was approved for six (6) non- ambulatory residents, which all 6 may be on hospice. Upon entry, LPA observed one (1) staff and two (2) residents present during inspection. Starting at 10:20 AM, LPA toured facility with ADM including but not limited to six (6) bedrooms, three (3) bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 6 bedrooms are private. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 114.3 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supple of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 7/7/2021. First aid kit was observed to be complete. Continue on Lic809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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: K & J RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200987
	VISIT DATE: 06/30/2023

NARRATIVE

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Continued from Lic809

Starting At 11:50AM, LPA reviewed 2 of 2 staff records. At 12:27 PM, LPA reviewed 3 of 3 residents' record. At 1:02 PM, LPA reviewed a sample of 3 of 3 residents' medications.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

1. At 10:27AM, LPA observed a bed in the living room that staff are sleeping on.

2. At 11:12AM, LPA observed S2 does not have current administration certificate on file; Certificate expired on 12/17/2021.

3. At 12:00PM, LPA observed S1 with no first aid and CPR training on file

4. At 12:08PM, LPA observed S1 with no Lic500 (personnel record), Lic503 (Health screening), and Lic508 (Criminal record statement) on file. S2 does not have an Lic508 on file.

5. At 12:40PM, LPA observed during record review that R1, R2, and R3 with no Lic625 (Needs/service plan) on file.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/7/2023:
· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance

Exit interview conducted with ADM, appeal rights given and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2023 03:13 PM - It Cannot Be Edited

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: K & J RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200987
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by allowing S1 to work in the facility with no First aid and CPR training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed for S1 to attend First aid and CPR training and to submit proof of training to CCL by POC due date.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not maintaing staff records for S1, and S2; S1 does not have an Lic501 (Personnel record), 503 (Health screening), and 508 (Criminal record statement) on file, and S2 does not have an Lic508 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to fill out an Lic 501, 503, and 508 for S1, and for S2 an Lic 508 and to submit to CCL by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/30/2023 03:13 PM - It Cannot Be Edited

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: K & J RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200987
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not maintaining an Lic625 (Needs and service plan) for R1, R2, and R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to fill out an Lic625 form for R1, R2, and R3, and to submit to CCL by POC due date.

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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 06/30/2023 03:13 PM - It Cannot Be Edited

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: K & J RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200987
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(2)(B)

87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. 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 having a bed placed in the living room that staff are using for sleeping, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Submit to CCL by POC date. Administrator agreed to remove the bed from the living room and to submit a picture as proof.

Type B

Section Cited

CCR

87412(d)

87412(d) Personnel Records: (d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above in not having a current administrator certificate on file for S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	Administrator agreed to follow up with Sacramento's Administrator Certificate office to get S2's certificate and to submit proof of certificate to CCL by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

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