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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202810
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:22:01 PM

Document Has Been Signed on 04/28/2023 04:22 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 2FACILITY NUMBER:
435202810
ADMINISTRATOR:KAYKHA, ABDULLAHFACILITY TYPE:
735
ADDRESS:6264 BLOSSOM AVENUETELEPHONE:
(408) 675-5558
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 3DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator Abdullah KaykhaTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Simi Rai and Ravi Patel conducted an unannounced annual inspection visit and met with Administrator Abdullah Kaykha and Fatima Kaykha.

During visit, LPAs toured the inside and outside of the facility. LPAs toured the facility kitchen and observed at least 2 days of perishable food supply and at least 7 days of nonperishable food supply. Sharps and medications were locked in secured areas. There was a first aid kit in the facility. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The showers had non-skid mats, and shower chairs. Administrator stated the grab-bars will be installed in Bathroom #1.The water temperature in the bathroom sinks ranged from 114.7F - 116F. The water temperature in the kitchen sink was 120.3F. Fire extinguisher were observed and were inspected on April 2023.

Facility smoke and carbon monoxide detectors were tested and found to be in functioning condition. Three out of three resident bedrooms had available bedding, drawers, and functioning lights. LPAs reviewed facility records for six staff and three residents. LPAs reviewed resident medications and central stored medication records. LPAs interviewed 2 staff and 3 resident.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Administrator Abdullah Kaykha and Fatima Kaykha.. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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