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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208857
Report Date: 12/06/2022
Date Signed: 12/06/2022 03:49:00 PM

Document Has Been Signed on 12/06/2022 03:49 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AK'S HOME OF CARE LLCFACILITY NUMBER:
107208857
ADMINISTRATOR:MALHI, AKWANTFACILITY TYPE:
735
ADDRESS:122 W SAN GABRIEL AVETELEPHONE:
(559) 708-3485
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 4DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Akwant Malhi, AdministratorTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA met with Administrator Akwant Malhi. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Hand sanitizer was readily available to residents and visitors. Bathrooms and kitchen have trashcans with lid. Hand washing posters were observed by the bathroom and kitchen. Bedrooms were checked. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked. Cleaning and PPE supplies were checked. Resident’s files have updated emergency contact information.

Deficiencies cited on LIC809D.

Exit interview conducted. Administrator was provided with Appeal Rights.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: AK'S HOME OF CARE LLC
FACILITY NUMBER: 107208857
VISIT DATE: 12/06/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate


Please submit the above forms/information to Fresno CCL by: 12/13/2022.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2022 03:49 PM - It Cannot Be Edited


Created By: Lady Cabrera On 12/06/2022 at 03:15 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AK'S HOME OF CARE LLC
FACILITY NUMBER: 107208857

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Buildings and Grounds Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients

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, Clorox wipes containers and disinfectants spray cans were unlocked and found on the kitchen cabinet while clients were present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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Cleared at the time of the visit. Staff locked all chemicals and disinfectants.
Type A
Section Cited
CCR
80072(a)(2)
80072 (a)(2) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed a safety gate with a chain and a steel padlock separating the living room and the kitchen area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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Cleared at the time of the visit. Administrator removed the chain and steel padlock.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2022 03:49 PM - It Cannot Be Edited


Created By: Lady Cabrera On 12/06/2022 at 03:22 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AK'S HOME OF CARE LLC
FACILITY NUMBER: 107208857

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087(a) Buildings 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
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Based on observation, the licensee did not comply with the section cited above, client and staff bathroom had a strong smell of urine and the floor was wet with a liquid around the toilet, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2022
Plan of Correction
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Administrator will submit a cleaning protocol for the client and staff bathroom to CCL to address the issue by 12/08/22.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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