Pacific Care Assisted Living

Type of visit: Required - 1 Year

On 09/10/2026 at 09:05am, Licensing Program Analyst (LPA)Zina Brown arrived at the the facility to conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one year annual inspection. At 9:40am,the Department met with Anwer Khan (Administrator) and the purpose of the visit was discussed. Please be advised due to technical difficulties, the Department was unable to generate electronic inspection tool and instead used a printable PDF version. Facility is licensed to serve 6 non-ambulatory residents of which 1 maybe bedridden in bedroom #4 and a waiver granted for hospice care for 4 residents. None of the residents are diagnosed with dementia nor have any restricted health conditions and are not receiving home health, hospice care and palliative services. The facility does not handle any of the residents’ money. The facility holds a administrator certification #7031623740 for Anwer Khan which is valid from 09/25/2025 - 09/24/2027. The facility has liability insurance with James River (policy #00166956-0) effective date 10/23/2025 - 10/23/2026 with each occurrence $1,000,000 and general aggregate at $3,000,000. The facility fee were paid in full on 09/11/2026 (approval #09526G) during the time of this inspection. The home is a single story home with four (4) bedroom, two (2) bathroom, a garage, a living room, dining room, kitchen, laundry room and an backyard with a garden and an outdoor shaded area. LPA toured the Anwer Khan (Administrator) tour the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 105 °F - 120 °F (108.5 °F. in kitchen, 105.1 °F. in bathroom 1 & 111.5 °F in bathroom 2. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. The Department conducted a records review of (2)resident records, (2)staff records, (0) resident Personal & Incidental Records, and (2) Resident Medication Administration Records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); The observed the following deficiencies: Staff 1 (S1) no LIC 503 with TB Test Results. Staff 2 (S2) not associated to the facility in Guardian during the inspection. Resident 1 (R1) no LIC 503 with TB Test Results. Resident 1 (R1) & Resident 2 (2) no physician order for the use of postural supports such as bedrails. Exit interview conducted with Anwer Khan (Administrator) and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Sep 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 12, 2026

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) 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 Based on observation and interview S2 Johana Sigarlaki were not associated to the facility as the time of unannounced annual inspection which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: The facility shall associate S2 Johana Sigarlaki in Guardian and submit proof of update via email at zina.brown@dss.ca.gov by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)(11) · Plan of correction due date: Oct 2, 2026

(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11)A health screening as specified in Section 87411, Personnel Requirements - General. Based on observation and interview: S1 Anwer Khan did not have proof of LIC 503 Health Screening with TB Test Results which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: The facility will submit proof of LIC 503 with TB Test result for S1 Anwer Khan via email at zina.brown@dss.ca.gov by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Oct 2, 2026

(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff Based on observation and interview: R1 Ruby Turner did not have proof of LIC 602 Health Screening with TB Test Results which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: The facility will submit proof of LIC 602 with TB Test result for R1 Ruby Turner via email at zina.brown@dss.ca.gov by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Oct 2, 2026

(a) Based on the individual's preadmission appraisal. . . Postural supports may be used under the following conditions (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. Based on observation, interview and records review: R1 Ruby Turner with full bed rails & R2 Joseph Cook with half bedrails & the Dept did not observe proof of physician order indicating the need for postural support which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: The facility will submit proof of physician order indicating the need for postural support for bedrails for R1 Ruby Turner & R2 Joseph Cook via email at zina.brown@dss.ca.gov by POC due date.

Type of visit: Prelicensing

On September 25, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted announced visit to this home. LPA was greeted by applicant and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 03/25/25 in the initial license application for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which maybe five (5) non-ambulatory, and one (1) bedridden. Structure: The home is a four (4) bedroom, two (2) bathroom, one story home with a two (2) car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living room did include a faux fireplace. The living area included sofa and recliners. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility had four (4) bedrooms for residents. There are four (4) bedrooms for non-ambulatory residents and (1) of the bedrooms specific to the bedridden. All rooms include a twin-size bed, one (1) chair, one (1) night stand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. The room also included wall night lights. Evaluation Report Continues Bedrooms Staff: There is no bedroom designated for live-in staff. Bathrooms: The home has two (2) bathrooms. Bathrooms are accessible in all rooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats. Linens & Hygiene Supplies: Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet inside the bedrooms. Emergency Phone Numbers, Exit Plan & Menu: Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is one (2) fire extinguisher located in the kitchen mounted on the wall. A telephone line is available in the kitchen, living, and dining rooms. Emergency supplies and Personal Protective Equipment supplies are stored in the dining room area. The applicant as an approved Infection Control Plan on file. Food Service: Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen drawer. The food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances. Smoke Detectors: Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is located in the hallway. Toxins: All toxins are locked and stored under the kitchen sink cabinet. Evaluation Report Continues Fire clearance: A Fire Clearance inspection was conducted on 07/30/25 approved for a capacity for five (5) non-ambulatory, one (0) for ambulatory, and one (1) for bedridden. Component III: LPA Dabuet conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint. An exit interview was conducted, and a copy of this report has been furnished to the applicant Anwer Khan. LPA Dabuet will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application. END OF REPORT Appliances: Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which included an air fryer, toaster, and coffee maker. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 40 degrees Fahrenheit for appropriate food storage. The home is equipped with central heating and air conditioning systems. Water Temperature: The water temperature is 111.8 degrees throughout the kitchen and bathrooms. Medications, First-Aid Kit & Book: A first aid kit is stored in the medication cabinet inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in the same medication cabinet locked in the hallway area. Resident & Staff Files: The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in a locked cabinet in the hallway. Reading Material, Games, Equipment & Materials: The facility has board games, books, magazines, and other recreational materials for the residents’ use all stored in the living room. Pool/Jacuzzi & Pets: There are no pets, jacuzzi, or pools in the fenced area. Evaluation Report Continuesthe state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Anwer Mohammed Khan CEO/Administrator Interview Method: Telephone interview On August 29, 2025, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-Licensing Readinessthe state’s words, verbatim · CDSS document, Aug 29, 2025