<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202810
Report Date: 04/27/2022
Date Signed: 04/27/2022 03:07:08 PM

Document Has Been Signed on 04/27/2022 03:07 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 2FACILITY NUMBER:
435202810
ADMINISTRATOR:KAYKHA, ABDULLAHFACILITY TYPE:
735
ADDRESS:6264 BLOSSOM AVENUETELEPHONE:
(408) 675-5558
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Abdullah KaykhaTIME COMPLETED:
03:08 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility to conduct an unannounced annual inspection at approximately 01:25 PM. LPA met with facility administrator Abdullah Kaykha (Admin).

The facility currently has no residents, as they have not yet completed the vendorization process with SARC. Facility bedrooms observed to contain various facility supplies and equipment. Admin stated that the facility is currently in the process of organizing storage for facility materials before vendorization is complete. All necessary storage space for potentially hazardous materials and substances, such as cleaning supplies and medications, were observed to have been implemented. All cleaning supplies and chemicals noted to be in locked cabinets and closets.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in April 2022. Smoke alarms were tested and observed to be functioning properly.

Facility observed to have a designated entry point. Staff took LPA's temperature but did not screen for symptoms. Facility observed to have 30 days supply of PPE. Social distancing signs not observed to be posted in all public areas. Hand washing signs were not observed in facility bathrooms. Water temperature observed to be 108.3*F.

No deficiencies cited during today's visit. Advisory notes issued. This report was reviewed with Administrator Abdullah Kaykha and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1