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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202908
Report Date: 08/13/2024
Date Signed: 08/15/2024 08:05:43 AM

Document Has Been Signed on 08/15/2024 08:05 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
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: 6DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:ABDULLAH KAYKHATIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez conducted an unannounced annual inspection visit, and met with Administrator (ADM) Abdullah Kaykha. During the visit, LPA observed 1 residents and 1 staff.

The facility serves adults ages 18 to 59 years old, who are developmentally disabled. 6 ambulatory of which 2 maybe non-ambulatory.

At 9:20 a.m. Licensed Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez observed 7 Cameras on the Facility 2 cameras in the front and 4 Cameras inside in the common area and 1 camera in the backyard.

LPAs toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

LPAS observed 2 day of non-perishable and 7 day nonperishable food supplies. LPAs observed the medication, knives and cleaning product are locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 134.7 degrees F in both resident bathrooms Kitchen Sink was measured at 136.4.

Fire extinguisher was serviced in 05/18/2023 The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPAs observed has a first aid kit that is complete and accessible to staff. Facility recently accepted resident July 15, 2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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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: 08/13/2024
NARRATIVE
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LPAs reviewed facility records for 3 staff and 2 residents. LPAs reviewed 2 resident medications and centrally stored medication records. LPAs conducted interviews with 2 staff and 1 resident. LPAs checked Guardian and S1 and S2 does not have California Clearance prior to working at the facility. S1s live scan was on the wrong form. S2 stated that he/she does not have a live scan. LIC/ADM stated that per Guardian, they will only acquire a livescan if it was requested and when notified by Guardian. LIC/ADM stated that two other employees works at the facility. LPAs checked the association of employees. LPAs observed that two are not associated with the facility. LIC/ADM stated that he/she is not able to associate the employees through Guardian because he cannot access the facility agency portal and the facility is not listed when he/she tries to access the agency portal.

LPAs discussed with licensee the importance of associating employees and obtaining criminal record clearance for all individuals prior to working, volunteering or residing in the facility. LPAs discussed with LIC/ADM the importance of having the record completed and available for inspection at all times.

LPA requested the following documents be sent to CCLD. LIC 500 (Personnel Summary)
LIC 308 (Designation of Administrative Responsibility)

Deficiencies are cited during today's visit per California Code of Regulation (CCR) Title 22.
See LIC 809D. An exit interview was conducted with LIC/ADM Abdullah Kaykha and Fatemeh Kaykha. A copy of the report and appeals rights were provided.

80054 Penalties (b) Notwithstanding Section 80054(a)...an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1522(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 80019(e) prior to working, residing or volunteering in the facility.

end of report
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This report was reviewed with Administrator Abdullah Kaykha and Fatemeh Kaykha.. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2024 09:34 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/23/2024 09:18 AM


Created By: Maria Partoza On 08/13/2024 at 01:59 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
CENTRAL COAST CR/RES, 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: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)(3)(4)
80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or (4) Request and be approved for a transfer of a criminal record exemption

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not obtaining a California clearance for S1 and S2. LIC/ADM stated there are other employees that needs to be associated. LIC ADM stated he cannot access Guardian for AK Home 3 to associate S3 & S4, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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LIC/ADM sent S1 and S2 to obtain a live scan. LIC/ADM will associate S3 and S4 by faxing over information of S3 and S4 to CCLD office by using form LIC 9182 and required documents.
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies (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 the licensee did not comply with the section cited above by not maintaining hot water temperature of not less than 105 degrees F and not more than 120 degrees F. LPAs measured water temperature using a digital thermometer from 2 bathroom and kitchen sink and measured at 134.7 degree F to 136.4 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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LIC/ADM stated will maintain the water temperature as required. LIC/ADM stated it will take about 5 to 8 hours for the water temperature to regulate at 105 degree F to 120 degree F and will email a photo of the regulated water temperature to LPA by the correction due date.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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