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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202884
Report Date: 04/24/2026
Date Signed: 04/24/2026 09:22:40 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2026 and conducted by Evaluator Marcela Yanez
COMPLAINT CONTROL NUMBER: 26-AS-20260211123215
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: 4DATE:
04/24/2026
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Josefina GervacioTIME COMPLETED:
09:35 AM
ALLEGATION(S):
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Staff did not follow resident's medication prescription.
Staff is not properly trained to administer medications.
Administrator is not present at facility for number of hours necessary.
INVESTIGATION FINDINGS:
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On April 24, 2026, Licensing Program Analyst (LPA) conducted an unannounced complaint investigation visit to deliver findings. LPA announced the purpose of the visit and met with Lead Staff Josefina Gervacio.

On February 11, 2026, the department received a complaint with the above allegations.

On February 19, 2026, LPA Yanez conducted an initial complaint investigation visit and interviewed 3 residents and 3 staff including Administrator (ADM).

3 out of 3 residents stated that that S1 was a live in staff and he/she would assist residents with administering medication, cooking and cleaning the facility. 3 out of 3 residents stated S1 would assist with other things as well. 3 out of 3 residents stated they like living at the facility. 3 out of 3 residents stated that S1 would go to the doctors with them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20260211123215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 LLC
FACILITY NUMBER: 435202884
VISIT DATE: 04/24/2026
NARRATIVE
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3 out of 3 staff stated S1 was a caregiver at the facility and a live in staff. 3 out of 3 staff stated S1 cooked, cleaned and assisted residents with ADLs. ADM and S2 stated S1 was trained to administer medication from the day he/she started and was provided hands on training. ADM stated S1 was trained according to regulation and S1 did not like signing any documentation. S2 stated he/she also trained S1 in medication management and direct support staff duties. 1 out of 3 residents stated he/she recalls S1 not wanting to sign documents but was not able to state what documents.

LPA reviewed S1s file and S1 was CPR certified as of January 30, 2026. S1 also received training but refused to sign orientation checklist sheet. S1 agreed to train new staff when he/she resigned and when new staff were hired. Based on interviews S1 did receive hands on training in administering medication.

1 out of 3 residents’ medication record showed resident was given medication per doctor’s orders. R1 stated he/she took all his/her medication according to doctors’ orders. LPA reviewed medication record for R1 which showed ADM signature on medication administration record and medication was dispensed as prescribed. LPA conducted an audit of R1s medication and found no discrepancies. ADM stated R1 did have PRN medication, and it was destroyed after R1s symptoms subsided.

1 out of 3 residents stated that they see the Administrator (ADM) at the facility everyday and he/she leaves the facility around 3 PM. 1 out of 3 residents stated that ADM is at the facility for 1 hour. 1 out of 3 staff stated ADM is at the facility during the day when Residents are at day program and leave’s around 3 PM. LPA reviewed the Staff schedule for January, February and March which shows the administrator is at the facility from 3-11 PM. S3 stated ADM has a scheduled appointment every day at 3 PM and returns to facility and stays till around 9 PM. ADM provided a weekly schedule for week of April 19, 2026, which states ADM is at the facility from 6-10 AM and between 7-9 PM

On April 24, 2026 the department concluded its investigation.

Based on investigation, interviews conducted, and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.
This report was reviewed with Administrator and a copy of the report was provided.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2