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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202908
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:25:35 PM

Document Has Been Signed on 12/23/2024 12:25 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: DATE:
12/23/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Abdullah KaykhaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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A Noncompliance meeting was conducted on December 23, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analyst Manuel Monter, Administrator Abdullah Kaykha

The purpose of the noncompliance meeting was to discuss the history of facility's serious violations cited under Title 22 California Code of Regulations to include Criminal Record Clearance, Furniture, Fixtures, Equipment & Supplies, Responsibility for Providing care & Supervision, Modification to Needs & Services Plan, Administrator- Qualifications & Duties.

During today's visit, other facilities operated by the Licensee were discussed which included AK Home 1 and AK Home 2.

Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections. The San Bruno Adult and Senior Care - San Jose Unit will refer the facility for legal consultation which may result in administrative actions such as possible Administrator De-Certification, License Revocation, or Employee Exclusion.

RO will refer the facility to the Department’s technical support program (TSP) and provided a TSP brochure, Community Care Licensing Division (CCLD) website www.cdss.ca.gov.
Report was reviewed with Licensee representatives. A copy of this report, LIC 9111 was provided to Licensee representatives during today's office visit.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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