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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202908
Report Date: 09/09/2024
Date Signed: 09/09/2024 05:51:07 PM

Document Has Been Signed on 09/09/2024 05:51 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 3FACILITY NUMBER:
435202908
ADMINISTRATOR/
DIRECTOR:		KAYKHA, ABDULLAHFACILITY TYPE:
735
ADDRESS:6051 PINELAND AVENUETELEPHONE:
(408) 675-5558
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 1DATE:
09/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Administrator Abdullah KaykhaTIME VISIT/
INSPECTION COMPLETED:
05:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez conducted an unannounced case management visit in regards an incident report, which stated a resident had eloped from the facility. LPA's met with Administrator Abdullah Kaykha. LPA's explained the purpose of the visit.

On September 6, 2024, the Department received an incident report, regarding resident R1. The incident report stated On September 5, 2024 at about 6:10pm staff called the administrator and reported that R1 has left the care home without any notifications. He/she looked out but could not see R1. He/She called 9-1-1 and reported AWOL. In about an hour SJPD brought R1 back to the care home. R1 stated he/she went to a random home and asked the to call SJPD for him/her.

On September 9, 2024, the Department received an incident report regarding resident R1. The incident report stated on September 6, 2024, at about 2:50pm, staff called the administrator and reported that R1 is saying that he/she wanted to run away to visit their family members, and as he/she was speaking on the phone he/she just left the home and staff could not keep him/her. The 9-1-1 was called and reported AWOL again. In about an hour SJPD brought R1 back to the care home.

On September 9, 2024, the Department received an incident report regarding resident R1. The incident report stated on September 7, 2024 at about 1:30pm staff called the administrator and reported that R1 has initiated another AWOL and forced him/herself out of the home to visit his/her family member. Staff called 9-1-1 and within a few minutes SJPD appeared at the care home and interviewed the staff about the incident. SJPD contacted the office and within 20 minutes another colleague found R1 in the neighborhood and he/she was brought back with 10-15 minutes.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: AK HOME 3
FACILITY NUMBER: 435202908
VISIT DATE: 09/09/2024
NARRATIVE
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On September 9, 2024, LPA's interviewed facility ADM and Licensee. LPA asked ADM what was his plan of action after the elopement the first elopement on September 5, 2024. ADM stated, “ what could we do. “ ADM stated he has raised his voice to ask to remove the resident from the home. ADM stated asked the staff to keep eyes on the resident. ADM stated they ordered a door alarm but it hasn’t come in yet. ADM stated R1 does not have 1 on 1 care giver. LPA requested to see R1's pre-admission appraisal. ADM stated he sent the form family and case manger. ADM stated they don't have a pre-admission appraisal to show LPA right now. ADM stated the form was not filled out. Licensee stated when R1 moved in, they did not know R1. ADM stated before R1 moved in, they had a copy of R1's IPP.

LPA's interviewed S1. S1 stated R1 has expressed in the past to him/her regarding running away. S1 stated R1 attempted to elope on September 2, 2024, but S1 stated he/she was able to re-direct her. S1 stated resident R1 is always trying to run away. S1 stated R1 cannot leave by herself. S1 stated R1 eloped on last, Friday, Saturday.

Based on a review of R1's Individual Program Plan, dated October 9, 2023, Resident R1 "needs consistent supervision from a responsible adult throughout each day to ensure her health and safety and to help provide him/her emotional support." The IPP also states, "as noted prior, parents do feel that R1 is naive and trusting so stranger danger is a concern as well."

Based on a review of R1's Needs and Services Plan, dated August 2, 2024. The needs and services does not address resident R1's elopement behavior. LPA asked ADM if he updated the needs and services plan, ADM stated he has not.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Abdullah Kaykha. Appeal rights were provided. Licensee/adminsitrator refused to sign. They both stated they are to emotional to sign.

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/09/2024 05:51 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/09/2024 at 04:21 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: AK HOME 3
FACILITY NUMBER: 435202908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/10/2024
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a)(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by;
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ADM stated he will send letter of understanding regarding the regulation. ADM stated she will send letter to LPA by POC date, September 10, 2024.
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Based on record review, R1 has limited safety awareness and should not be left unattended. ADM acknowledged R1 has left the facility unattended on 9/5/2024, 09/06/2024 & 09/07/2024. This poses/posed an immediate health, safety or personal rights risk to persons in care.
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Request Denied
Type A
09/10/2024
Section Cited
CCR80068.3(a)

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80068.3 Modifications to Needs and Services Plan (a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, ... shall be maintained in the client's file. This requirement was not met as evidenced by;
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ADM stated she will send letter of understanding regarding the regulation.

ADM stated he will send a copy of an updated needs and services plan, which address R1's elopement behavior.
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Based on interview, ADM stated he does not have an updated needs and services plan for the R1, which address his/her elopement behavior. ADM stated he did not update R1's needs and services plan after the elopement. This poses/posed a immediate health, safety or personal rights risk to persons in care.
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ADM stated he will send the plan of correction to LPA by POC date, September 10, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/09/2024 05:51 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/09/2024 at 04:54 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: AK HOME 3
FACILITY NUMBER: 435202908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/10/2024
Section Cited
CCR
80064(a)(2)

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80064 Administrator - Qualifications and Duties (a)(2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients.
This requirement was not met as evidenced by;
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ADM stated he will send a letter of understanding regrading the regulation. ADM stated she will send the letter by POC date, September 10, 2024.
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Based on records reviewed and interviews conducted, the facility did not have a pre-admission apprisal for R1. The facility did not have an updated needs and services plan for R1 after his/her elopment on 09/05/2024. This poses/posed an immideate health, safety or personal rights risk to persons in care.
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Request Denied
Type B
09/16/2024
Section Cited
CCR85068.1(b)

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85068.1 Admission Procedures (b) No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2. This requirement was not met as evidenced by;
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ADM stated she will send letter of understanding regarding the regulation. ADM stated he will send a copy of R1's pre-admission appraisal. ADM stated he will send plan of corrections to LPA by POC date September 16, 2024.
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Based on records reviewed and interview conducted, ADM stated he did not conduct a pre-admission Appraisal for resident R1. This poses a potential health, safety or personal rights risk to persons in care.
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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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
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