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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202908
Report Date: 02/12/2025
Date Signed: 02/12/2025 04:36:44 PM

Document Has Been Signed on 02/12/2025 04:36 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: 2DATE:
02/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Abdullah KaykhaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Abdullah Kaykha, Administrator (ADM), and Shana Kaykha.

The purpose of the visit was to follow up on an Unusual Incident/Injury Report (IR) that the facility submitted to the department on 01/21/2025. The IR stated that on 01/20/2025 at about 10:30 AM, resident R1 snatched a basket containing R1's medications from a staff while the staff was reviewing medications. R1 then ran into R1's bedroom. The staff was able to retrieve the medications, but the staff observed that R1 had taken a tablet from one of the blister packs. On the same day, at around 2:30 PM, another staff observed that R1 became aggressive and forced the locked medication cabinet open and took R1's medications back into R1's bedroom again. Staff immediately forced himself/herself into R1's bedroom and observed that R1 had consumed one of the medications. Staff called 911. Local law enforcement arrived at the facility and took R1 to an emergency psychiatric service facility.

During visit, LPA observed the locked staff bedroom and cabinet within the locked staff bedroom where the resident medications are now stored. ADM stated that staff are aware of where the medications are being stored and have the keys to access the medications.

ADM stated he will work with R1's care team to update R1's Appraisal/Needs and Services Plan to reflect the change in R1's behavior, including R1 taking medications into his/her bedroom and consuming medications outside of prescribed times. LPA Marrufo requests a copy of R1's updated Appraisal/Needs and Services Plan by 02/19/2025

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with ADM Abdullah Kaykha and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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