<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200681
Report Date: 03/01/2024
Date Signed: 03/01/2024 06:23:32 PM

Document Has Been Signed on 03/01/2024 06:23 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:
03/01/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Kiptiau Iscandari/LicenseeTIME COMPLETED:
06:30 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
At 2:20 p.m. on this day, March 1, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on February 14, 2024. LPA was granted entry by staff, Dzul Iscandari, and informed the reason for visit. Kiptiatu Iscandari, licensee, arrived at around 2:45 p.m.. Mohamed Conte, administrator, arrived at 4:30 p.m.

LPA reviewed 5 staff and 3 residents records, and interviewed 2 staff and 2 residents. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Record, and doctor's orders. Residents' P&I checked and compared with last recorded balance.

LPA observed the following:
-at 2:55 p.m., staff's (S2 and S3) First Aid certificates expired 12/05/23.
-at 3:00 p.m.. S3 has no TB test on file.
-at 3:30 p.m., residents' (R2 & R3) Appraisal/Needs and Services Plan were outdated.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. 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.

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

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: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 03/01/2024 06:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/01/2024 at 05:58 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: 03/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S3 not having TB test on file. which poses a potential health risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
1
2
3
4
Administrator to have the staff undergo TB testing and submit proof by 3/15/24.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R2 and R3's Appraisal/Needs and Services Plan outdated which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Administrator to complete the LIC625 Appraisal/Needs and Serices Plan, and submit self-certification by 3/08/24.
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: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/01/2024 06:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/01/2024 at 06:08 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: 03/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(F)
80075 Health Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S2 and S3's First Aid certificates expired which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
1
2
3
4
Administrator to have the staff register and complete first aid training, and submit copies of certificates by 3/15/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3