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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200681
Report Date: 02/14/2024
Date Signed: 02/14/2024 05:50:32 PM

Document Has Been Signed on 02/14/2024 05:50 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:A & K RESIDENTIAL HOMEFACILITY NUMBER:
019200681
ADMINISTRATOR:CONTEH, MOHAMEDFACILITY TYPE:
735
ADDRESS:19635 MEEKLAND AVETELEPHONE:
(510) 674-9151
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 3DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Mohamed Conteh/Administrator TIME COMPLETED:
05:50 PM
NARRATIVE
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At 4:05 p.m. on this day, February 14, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Mohamed Conteh, administrator, and informed the reason for visit. LPA also met with other staff, Mumcy Coker. Kiptiatu Iscandari, licensee, arrived at around 5:18 p.m..

The licensee submitted the facility's Infection Control Plan which LPA received in June 2022.

LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has carbon monoxide and smoke detectors that were tested and observed functional. Facility conducts fire and earthquake drills at least every quarter, and records showed last conducted 1/08/24 and 2/11/24 respectively. Fire extinguisher checked, observed fully charge with tag showed serviced 7/24/23. Hot water temperature in the bathroom was tested.

Administrator to submit the following current/updated documents by February 28, 2024.
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

...continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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: A & K RESIDENTIAL HOME
FACILITY NUMBER: 019200681
VISIT DATE: 02/14/2024
NARRATIVE
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At 4:36 p.m., LPA observed hot water at 133 degrees Fahrenheit.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date. and any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with the administrator and licensee.

Due to time constraint, LPA has to come back to continue inspection.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2024 05:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/14/2024 at 05:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: A & K RESIDENTIAL HOME
FACILITY NUMBER: 019200681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in hot water at 133 degrees Fahrenheit which poses an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee and/or administrator to adjust the temperature and ensure it's kept within Regulations range. Proof to be submitted by 2/15/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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