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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202800
Report Date: 03/10/2023
Date Signed: 03/10/2023 02:54:28 PM

Document Has Been Signed on 03/10/2023 02:54 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
CENTRAL COAST CR/RES, 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:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Fatemeh KaykhaTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) David Marrufo and Tracy Pham conducted an unannounced Required 1 Year visit and Administrator Fatemeh Kaykha.

During visit, LPAs toured the facility inside and out. LPAs observed the kitchen area and observed food storage, first aid kit, and secured medication area. LPAs observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPAs observed chemical cleaning supplies stored in a locked area.

3 out of 3 resident bedrooms had beds with bedding, clothing drawers, and functioning lights. The smoke detectors in each bedroom and the carbon monoxide detector in the hallway all functioned properly when tested.

LPAs reviewed the resident medications, resident records, and staff records. There were no missing medications or missing records found during review. The outdoor are was observed and the exit was observed to be clear of obstructions.

1 out of 1 facility bathroom was observed to have water temperature at 124 F.

No deficiencies were cited at this time as per California Code of Regulations Title 22. An advisory note was issued. See LIC9102 for more information.

This report was reviewed with Administrator Fatemeh Kaykha and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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