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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202908
Report Date: 08/01/2023
Date Signed: 08/02/2023 08:09:41 AM

Document Has Been Signed on 08/02/2023 08:09 AM - 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 3FACILITY NUMBER:
435202908
ADMINISTRATOR:KAYKHA, ABDULLAHFACILITY TYPE:
735
ADDRESS:6051 PINELAND AVENUETELEPHONE:
(408) 675-5558
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
08/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Abdullah KaykhaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced pre-licensing inspection visit and met with Administrator (ADM) Abdullah Kaykha.

LPA toured the facility inside out with ADM. Personal Rights posters and Administrator Certificate were observed at the main entrance. Office, dining room, kitchen, 3 shared resident bedrooms, 2 restrooms, and laundry room were inspected.

Room temperature was observed at 71 degree F. Hot water temperature was observed at 102.9 degree F. ADM agreed to adjust the water temperature. Refrigerator temperature was observed at 36 degree F. Freezer temperature was observed at 0 degree F. All the bedrooms were observed with window screens.

Fire extinguisher was serviced on 05/18/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Medications closet was observed locked. Knives closet was observed locked. Detergent closet under the kitchen sink was observed not locked. The detergent closet in the garage was observed locked. ADM agreed to add a lock for the closet under the sink.

Nonskid pads were observed at the bathrooms. Night light was observed at the hallway. LPA toured the backyard with ADM. No obstruction were observed at the backyard. LPA discussed the infection Control Plan with ADM. Component III was conducted with ADM.

Exit interview was conducted with ADM. The report was provided to ADM for signatures. LIC809-D and Appeal Rights were attached. The reports were provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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Document Has Been Signed on 08/02/2023 08:09 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/01/2023 at 10:25 AM
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: AK HOME 3
FACILITY NUMBER: 435202908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds
(g) 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 evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above which poses an immediate health, safety risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Licensee agreed to submit a Plan of Correction by the POC due date to have a lock on the closet under the kitchen sink.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) 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 (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above which poses an immediate health, safety risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Licensee agreed to submit a Plan of Correction by the POC due date to adjust the water temperature to be between 105 degree F and 120 degree F.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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