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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202800
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:07:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20210607114206
FACILITY NAME:AK HOME 1FACILITY NUMBER:
435202800
ADMINISTRATOR:KAYKHA, FATEMEHFACILITY TYPE:
735
ADDRESS:497 SERENADE WAYTELEPHONE:
(408) 675-5558
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:6CENSUS: 3DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Abdullah and Fatemah KaykhaTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Lack of supervision resulting in inappropriate sexual interactions between residents while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Abdullah and Fatemah Kaykha.

On 06/07/2021, the Department received a complaint with the above allegation. The Department conducted an investigation visit to the facility on 06/08/2021. The Department obtained copies of resident and personnel records. In addition, the Department interviewed residents R1-R3, Administrators Fatemeh and Abdullah Kaykha, and staff S1, and also obtained a copy of the San Jose Police Department report made in response to the allegation.

See LIC9099-C for more information. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 26-AS-20210607114206
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: AK HOME 1
FACILITY NUMBER: 435202800
VISIT DATE: 12/09/2021
NARRATIVE
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R1’s behavioral assessment lists lying as one of R1’s targeted behaviors. R1 also has a history of making allegations of someone touching R1: In 2018, R1 accused former client R4 of touching R1 inappropriately. In 2019, R1 accused R5 of raping R1. Both incidents were unsubstantiated.

There were inconsistent statements about where and when the incident took place. R1 stated to R1’s counselor that R3 touched R1 in R1’s bedroom, that R3 continued to touch R1’s thigh, and R1 punched R3 to make R3 stop. However, R1 told San Jose Police Department the incident occurred in the living room, and that facility staff were present.

During interview with the Department, R1 stated the incident occurred in the hallway of the facility, and that R3 grazed R1’s thigh, vagina, and breast all in one motion. The Department investigator asked R1 for more information, and R1 stated to not remember.

During Interview, Administrator Fatemeh Kaykha stated that R1 has made allegations in the past about residents touching or sexually abusing R1. She stated that these incidents have been investigated. She has reviewed video footage from hallway cameras when R1 made prior accusations, and she did not observe R1 being sexually abused or assaulted.

During Interview, Administrator Abdullah Kaykha stated that R1 has a history of making allegations. He stated R1’s behavioral plan states that R1 has a behavior of making allegations. He stated that on May 2021, R1 had what seemed to him to be a panic attack while watching television in the living room with R2 and R3. R1 then went to R1’s room, and then left the facility to be with R1’s parent. Later, R1 was taken to the hospital. When the hospital discharged R1, nothing was found to be wrong with R1.


See LIC9099-C for more information. Page 2 of 3.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20210607114206
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: AK HOME 1
FACILITY NUMBER: 435202800
VISIT DATE: 12/09/2021
NARRATIVE
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Staff S1 stated to have not observed any resident inappropriately touch R1.

Resident R2 declined to be interviewed. Resident R3 stated during interview to have not observed any inappropriate touching between R1 and R2.

Based on interviews with staff and residents and review of records, the Department finds that although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Abdullah and Fatemah Kaykha and a copy of the report was provided.

Page 3 of 3.

END REPORT
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3