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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202800
Report Date: 03/23/2023
Date Signed: 03/23/2023 04:14:23 PM

Document Has Been Signed on 03/23/2023 04:14 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:
03/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Fatemeh KaykhaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Fatemeh Kaykha. The purpose of the visit was to follow up with a incident that was reported by the facility involving a resident who grabbed and consumed another resident's medications from the dinner table while staff were distributing medications.

During visit, LPA Marrufo interviewed staff S1 and S2 and ADM. S1 and S2 stated that they have been trained by ADM to have one staff distribute medications while another staff observes and supervises the residents.

ADM stated that she has trained the staff to have one staff distribute medications while another observes and supervises the residents in order to ensure that an incident of a resident taking another residents medications does not occur again.

ADM stated she will submit training records of training conducted to address the incident to CCL by 03/27/2023.

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

This report was reviewed with ADM and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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