075601228-1-3-2025-15-AS-JCCR-DCKTSH-20250103135910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601228
Report Date: 01/03/2025
Date Signed: 01/03/2025 01:59:19 PM

Document Has Been Signed on 01/03/2025 01:59 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:	KC CARE HOME		FACILITY NUMBER:	075601228
ADMINISTRATOR/ DIRECTOR:	LEGASPI, EVELYN & OSCAR		FACILITY TYPE:	740
ADDRESS:	1866 CLAYTON WAY		TELEPHONE:	(925) 451-1803
CITY:	CONCORD	STATE: CA	ZIP CODE:	94519
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Osar Legaspi, Licensee		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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On 01/03/25 at 12:40 pm Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Oscar Legaspi and explained the purpose of the visit.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade.

The following deficiency was observed during the visit:

The fire extinguishers has not been serviced since 11/9/2023

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

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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Document Has Been Signed on 01/03/2025 01:59 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: KC CARE HOME	FACILITY NUMBER: 075601228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 by not having their fire extinguishers replaced or serviced for over a year which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	The facility agrees to have their fire extinguishers relpaced or serviced. Proof of correction will be sent to CCLD by POC 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.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC809 (FAS) - (06/04)

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