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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202884
Report Date: 01/28/2026
Date Signed: 01/28/2026 03:04:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/28/2026 03:04 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/
DIRECTOR:		ZAREGHBEITI, KHOSROWFACILITY TYPE:
735
ADDRESS:5527 CENTURY MANOR COURTTELEPHONE:
(408) 621-6871
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 3DATE:
01/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Khosrow ZareghebeitiTIME VISIT/
INSPECTION COMPLETED:
03:15 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
LPA Audrey Jeung toured facility and grounds, including detached storage structure in backyard. There are three client bedrooms, one of which is a master bedroom with private full bathroom. There is a common bathroom, and open floor plan that includes kitchen, dining and living room. Washer and dryer are located in two car garage, which has been remodeled and serves as a storage room with door and full bathroom. There are no accessible bodies of water nor fire safety hazards observed. Nest Protect carbon monoxide detector is operable. Food supply and first-aid kit are inspected, and hygiene items for general use are maintained. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as required staff records. Marjan Gholizadeh and Khosrow Zareghebeiti are ARF administrators (x 4/26 and 9/27) that oversee facility operations. There is no staff room. Client files are reviewed, including Centrally Stored Medications Records. One client is over age 60, and administrator is advised that annual MD reports and appraisals must be maintained.



Deficiencies of the California Code of Regulations, Title 22, are cited on following pages. See also Technical Advisory Notes issued--2 pages.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
Document Has Been Signed on 01/28/2026 03:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/28/2026 at 01:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: M&K ADULT CARE LLC
FACILITY NUMBER: 435202884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2026
Section Cited
CCR
80075(k)(1)

1
2
3
4
5
6
7
HEALTH RELATED SERVICES
Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
This requirement is not met, as OTC Lomeramide is stored in bathroom in room
1
2
3
4
5
6
7
Loperamide was removed from clients' bathroom in LPA's presence.
Deficiency corrected and cleared
8
9
10
11
12
13
14
of clients #1 and #2, who are unable to self store and administer their own medications. Licensee failed to ensure that medications are inaccessible to clients, which poses an immediate health, safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
Type A
01/28/2026
Section Cited
CCR80087(g)

1
2
3
4
5
6
7
BUILDINGS AND GROUNDS
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met, as plant fertilizers & Repels All (pesticide) are observed on
1
2
3
4
5
6
7
Pesticide and fertilizers were relocated to detached storage shed and locked in LPA's presence.
Deficiency corrected and cleared.
8
9
10
11
12
13
14
rear deck, accessible to clients. Licensee failed to ensure that toxins are inaccessible to clients, which poses an immediate health, safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 01/28/2026 03:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/28/2026 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: M&K ADULT CARE LLC
FACILITY NUMBER: 435202884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2026
Section Cited
CCR
80088(e)(1)

1
2
3
4
5
6
7
FIXTURES, FURNITURE, EQUIPT...
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F & not more than 120 degrees F
1
2
3
4
5
6
7
Hot water temperature shall be lowered and maintained within range of 105 to 120 degrees F.
Plan/proof of correction to be sent to CCLD BY DUE DATE
8
9
10
11
12
13
14
This requirement is not met, as hot water temperature in client bathroom tested at 156 degrees F. Licensee failed to ensure that hot water temperature is maintained within range of 105 and 120 degrees, which poses an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type A
01/29/2026
Section Cited
CCR80075(k)(7)(A-H)

1
2
3
4
5
6
7
HEALTH RELATED SERVICES
The licensee shall ensure the maintenance, for each client, of a record of centrally stored Rx medications which ...includes...name of the client for whom prescribed, name of the prescribing physician, drug name, strength, quantity, the issuing pharmacy, expiration
1
2
3
4
5
6
7
All clients' medications that are centrally stored will be recorded on Centrally Stored Medications Records and reflect information on Rx labels.
Medications that are discarded or destroyed will also be documented, including quantities.
Proof of corrections will be sent to CCLD BY DUE DATE.
8
9
10
11
12
13
14
date, number of refills, instructions...This requirement was not met, as Rx medications for ALL clients are not recorded on Centrally Stored Medications Records--3 Rx meds, including 4 bottles of Hydroxyzine for C3, 5 Rx meds for C1, 9 rx meds for C2, plus non- Rx Rybelsus 14 mg (x7/27)
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/28/2026 03:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/28/2026 at 02:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: M&K ADULT CARE LLC
FACILITY NUMBER: 435202884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2026
Section Cited
CCR
85088(c)(2)

1
2
3
4
5
6
7
FIXTURES, FURNITURE, EQUIPT...
The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene...bedroom furniture... for each client, a chair, a night stand, and a lamp or lights necessary for reading.
1
2
3
4
5
6
7
Chair and/or nightstand will be installed in room of client #3, and proof of correction to be sent to CCLD BY DUE DATE
8
9
10
11
12
13
14
This requirement is not met, as there is no chair in room of client #2. Licensee failed to ensure that bedroom furniture includes chair for each resident in his room, which poses a potential health, safety or personal rights risk.
8
9
10
11
12
13
14
Type B
02/11/2026
Section Cited
CCR80075(f)

1
2
3
4
5
6
7
HEALTH RELATED SERVICES
Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met, as there is no proof that 2 out of 5 staff have valid
1
2
3
4
5
6
7
Proof of current first aid training for S1, S3 will be sent to CCLD BY DUE DATE
8
9
10
11
12
13
14
1st aid training, which poses a potential health, safety or personal rights risk to clients in care. Licensee failed to ensure that all staff who provide personal care have documentation of current first aid training. No proof of first aid for Staff #1, #3.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/28/2026 03:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/28/2026 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: M&K ADULT CARE LLC
FACILITY NUMBER: 435202884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2026
Section Cited
CCR
80065(g)(1)

1
2
3
4
5
6
7
PERSONNEL REQUIREMENTS
...good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or 7 days after employment or licensure. This requirement is not met, as
1
2
3
4
5
6
7
Health screening, including TB test results, will be sent to CCLD BY DUE DATE for S1, S3, S4
8
9
10
11
12
13
14
3 our of 5 staff do not have health screening on file. Licensee failed to ensure that all staff maintain valid health screening, which poses a potential health, safety or personal rights risk to clients in care. No health screening for S1, S3, S4
8
9
10
11
12
13
14
Type B
02/11/2026
Section Cited
HSC1565

1
2
3
4
5
6
7
HEALTH AND SAFETY CODE
A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals... is not required during a drill.
1
2
3
4
5
6
7
Emergency disaster drills shall be conducted quarterly and documented.
Plan/proof of correction to be sent to CCLD BY DUE DATE
8
9
10
11
12
13
14
While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff...,.There is no record of drills.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6