019200681-3-12-2026-15-AS-ADEO-DS53JJ-20260312181739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200681
Report Date: 03/12/2026
Date Signed: 03/12/2026 06:17:53 PM

Document Has Been Signed on 03/12/2026 06:17 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 HOME		FACILITY NUMBER:	019200681
ADMINISTRATOR/ DIRECTOR:	CONTEH, MOHAMED		FACILITY TYPE:	735
ADDRESS:	19635 MEEKLAND AVE		TELEPHONE:	(510) 674-9151
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 6		CENSUS: 4	DATE:	03/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Mohamed Conteh/Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:20 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 this day, March 12, 2026, at 2:00 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection and met with staff, Mumcy Coker, and informed the reason for visit. LPA spoke over the phone with Kiptiatu Iscandari, licensee, who stated Mohamed Conte, administrator (ADM) will come to the facility. Licensee gave permission to Mumcy Coker to be with LPA during inspection. ADM arrived at around 2:30 pm. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, front, side and backyard. Food supplies were checked and observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has smoke and carbon monoxide detectors that were observed in operating condition on this day. Hot water temperature in the common bathroom was tested and measured at 111.7 degrees Fahrenheit. Fire extinguisher checked, observed fully charge with tag showed serviced on December 3, 2025. LPA reviewed 5 staff and 4 residents records. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Residents' P&I checked and compared with last recorded balance. .....continued on 809C

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 03/12/2026

NARRATIVE

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LPA observed the following:
-at 2:21 pm, pieces of wood, broken garden table, large empty bottle of Dawn dishwashing liquid, broken statue, broken window screen, soiled wicker basket, pieces of metal tubes and bricks in the backyard.
-at 2:22 pm, TV, pieces of wood and brick in the side yard.
-at 2:50 pm, facility last conducted fire drill on November 12, 2025 and earthquake drill on December 12, 2025.
-at 4:30 pm, resident's (R4) P&I in facility's hand is more compared with the recorded balance.

Deficiencies and plan and proof of correction were discussed with the administrator. A $250.00 civil penalty is assessed for repeat violation of section 80087(a) within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalty.

Deficiency, plan and proof of correction and civil penalty were discussed with the administrator.

LPA obtained copies of the following current/updated documents:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/12/2026 06:17 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 03/12/2026 at 05:26 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: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 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 the following which pose a potential safety and/or personal rights risk to persons in care: pieces of wood, broken garden table, large empty bottle of Dawn dishwashing liquid, broken statue, broken window screen, soiled wicker basket, pieces of metal tubes and bricks in the backyard; TV, pieces of wood and brick in the side yard. This is a repeat violation within 12 month period.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	Administrator to have the yard cleaned and submit pictures by 3/26/26. A $250.00 civil penalty is assessed.

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. 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 not conducting disaster drills at least every quarter which poses a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	Administrator to have drill conducted and submit proof by 3/26/26

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

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/12/2026 06:17 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 03/12/2026 at 05:36 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: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(h)(1)

80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. 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 resident (R4)'s actual P&I not matching the recorded balance which poses a potential personal rights risk to person in care.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	Administrator to review and submit copy of corrected record by 3/26/26.

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.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC809 (FAS) - (06/04)

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