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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202884
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:39:43 PM

Document Has Been Signed on 01/19/2023 03:39 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:M&K ADULT CARE LLCFACILITY NUMBER:
435202884
ADMINISTRATOR:ZAREGHBEITI, KHOSROWFACILITY TYPE:
735
ADDRESS:5527 CENTURY MANOR COURTTELEPHONE:
(408) 621-6871
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: DATE:
01/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Khosrow ZareghbeitiTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted a Pre-Licensing visit and met with Administrator Khosrow Zareghbeiti.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed the facility had secure storage for medications. The facility had 3 bedrooms with available lighting, bedding, and drawers. The outdoor area exits were clear of obstructions. 1 out of 1 resident bathroom had water temperature at 110 F.

The outdoor fence had a portion of the fence which had been knocked down due to strong winds, according to Administrator. Administrator stated he will submit photographs of the fence once it is fixed to LPA. Administrator stated a repair service will come repair the fence as soon as weather permits.

LPA Marrufo reviewed Component III with Licensee/Administrator Khosrow Zareghbeiti.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Khosrow Zareghbeiti and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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