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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202800
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:09:44 PM

Document Has Been Signed on 03/27/2024 04:09 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
Lookup Error,
, CA
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:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Fatemeh KaykhaTIME COMPLETED:
04:45 PM
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On 3/27/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Fatemeh Kaykha. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. Three residents were observed to be watching tv in the living are and two were in Adult Day Programs. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 109 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked and inaccessible to residents. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill will is done every quarter.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Staff have current First Aid/CPR certifications on file.

Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated. PNI money was counted and all accounted for.

No deficiencies being cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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