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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202800
Report Date: 03/05/2025
Date Signed: 03/10/2025 11:11:11 AM

Document Has Been Signed on 03/10/2025 11:11 AM - 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/
DIRECTOR:
KAYKHA, FATEMEHFACILITY TYPE:
735
ADDRESS:497 SERENADE WAYTELEPHONE:
(408) 675-5558
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 4DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Fatemeh KaykhaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Fatemeh Kaykha.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be locked drawers for medications and sharp objects. LPA toured the food supply in the kitchen and garage area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the first aid kit to be complete.

LPA toured three out of three bedrooms and observed there to be working lights and available bedding and clothing storage areas. LPA toured two out of two bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks measured at 115 F and 116 F.

LPA tested the smoke detectors in the living room, hallway, and three out of three bedrooms. Each smoke detector functioned properly when tested. LPA tested the facility carbon monoxide detector and it functioned properly when tested.

LPA toured the outside area of the facility and observed the exterior exit to be clear of obstructions.

LPA reviewed Centrally Stored Medication and Destruction Records, Personal and Incidental Money Logs, and resident records for four out of four residents and all the records were complete. LPA reviewed 5 staff records and found them to be complete. The Emergency Disaster Drill Log indicates the last drill was conducted on 12/13/2024.

No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Fatemeh Kaykha and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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