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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202800
Report Date: 06/06/2022
Date Signed: 06/06/2022 04:41:25 PM

Document Has Been Signed on 06/06/2022 04:41 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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: 5DATE:
06/06/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Fatemeh KaykhaTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager (LPM) Jackie Jin, and Program Clinical Consultant (PCC) Nurse Cristina Wong conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Jocelyn Perez.

Administrator Cristobal reports that there are currently 2 COVID-19 positive residents and 2 COVID-19 positive staff.

During today's tele-visit, PCC Nurse Cristina Wong made the following recommendations to the facility:

1. Test 2 times per week for response driven testing on 06/07, 11, 14, and 18/2022.
2. Implement a Visitor Symptom Screening log at the entrance.
3. Post PPE Donning and Doffing posters in facility for staff.
4. Dish towels and cloth towels should not be used in the kitchen. Use only paper towels.
5. Have staff fit tested for N95 masks.
6. Review the following PINs: 22-04-CCLD, 22-15-ASC, 22-16-ASC, 22-07-ASC, 21-10-ASC.
7. Use anti-viral cleaning products for disinfecting bathrooms.

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

This report was reviewed with with Administrators Abdullah and Fatemeh Kaykha. A copy of the report will be sent to them for it be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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