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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208857
Report Date: 10/06/2023
Date Signed: 10/06/2023 12:02:14 PM

Document Has Been Signed on 10/06/2023 12:02 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
FRESNO RO, 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: 6DATE:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sandeep KaurTIME COMPLETED:
12:15 PM
NARRATIVE
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On 10/06/23 at 8:00 AM, Licensing Program Analyst (LPA) M. Flores arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and met with staff, Sandeep Kaur.

LPA tour the inside and outside of the facility. The facility was observed to be at a comfortable temperature of 74 degrees F, clean, in good repair, and no passageway obstructions. An adequate supply of perishable and non-perishable food was observed. Cleaning supplies and chemicals are stored and locked in a cabinet outside the garage. Sharps and medications are kept in a locked cabinet in the living room. All bedrooms were observed to have required furnishings and with adequate lightening. LPA observed four bedrooms. Bathroom is properly equipped, and the hot water temperature was tested at 105.58 degrees F. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of staff and client’s files were reviewed. First Aid checked and fully stocked.

LPA observed the following deficiency:

1. Fence is broken in the backyard. Side gate needs to be fixed. Side of the home need to be free of debris.

A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D.

The following updated forms are to be submitted to CCL by 10/20/23:

LIC308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9282, LIC999, Administrator certificate, and control of property.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with staff. A copy of this report and appeal rights were discussed and left with staff, Sandeep Kaur whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Miriam Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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 10/06/2023 12:02 PM - It Cannot Be Edited


Created By: Miriam Flores On 10/06/2023 at 11:43 AM
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: 10/06/2023

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
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Based on observation, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee agrees to submit photos of fixed gate, fixed fence and removal of debris on the side of the home by POC due date.
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:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
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