A1 Residential Care Facility

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to continue an Annual Required Evaluation. LPA was greeted by staff at 8am. LPA met with Muktar Mohamed, Administrator (AD) and explained the purpose of the visit. The facility is a single-story, four bedroom residence with three bedrooms designated for residents and one vacant bedroom designated for caregivers. The approved fire clearance is for six non-ambulatory residents in which one resident can be bedridden in bedroom #1. The facility has an approved hospice waiver for six resident. There are three residents in care and none receive hospice services. During today's visit, LPA toured the facility and tested the smoke detectors that are interconnected. The smoke and carbon monoxide detectors are operational. A fire extinguisher was charged and inspected on January 10, 2023. AD was advised to replace the fire extinguisher annually. The facility has three bathrooms but only one bathroom is used by residents. The bathroom was clean and grab bars and non-skid flooring were observed. The hot water temperature measured 114.4 degrees Fahrenheit. The facility's last fire drill was conducted on August 21, 2026. While touring the kitchen, LPA observed the sharps and knives were secured and cleaning supplies and hazardous chemicals were secured underneath the kitchen sink. The facility retained a minimum of two days of perishables and seven days of non-perishable food. AD stated he would be buying additional groceries and there was plenty of water available for residents in case of an emergency. (Continued from LIC 809) (Continued from LIC 809) LPA toured the exterior of the property and noted there were no hazards or obstructions blocking pathways. There was a covered seating area and ample room for outdoor activities. AD showed LPA the Junior Additional Dwelling Unit (JADU); as well as the separate address where staff reside. AD stated they will be changing their facility sketch and possibly renovating the facility to remove the JADU. AD will notify the Department if/when this occurs. Centrally stored medications were secured with the First Aid Kit in a locked cabinet. LPA reviewed the centrally stored medications. Per review, medications are being given as prescribed. The First Aid Kit had all of the required elements and a First Aid book is available. LPA reviewed two of two staff training and fingerprint records and conducted a complete review of resident records. One of two staff files were missing a health screening. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has an administrator certificate pending renewal. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Muktar Mohamed, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Sep 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)(11) · Plan of correction due date: Oct 23, 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 - (Continued) General. This requirement was not met as evidenced by: One of two staff members did not have a health screening on file. This poses a potential health and safety risk for three of three residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2026

Plan of correction: Licensee will submit LIC 503 Health Screening for the staff member by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by staff at 8am. LPA met with Administrator (AD), Muktar Mohamed, and explained the purpose of the visit The facility is a single story home with an approved fire clearance for six non-ambulatory residents; in which one resident may be bedridden in bedroom #1. The facility has an approved hospice waiver for six residents. Currently there are three residents in care and none of them receive hospice services. LPA provided AD with licensing fee payment information to pay fees online. LPA took a brief tour of the facility and had to leave the premises. An exit interview was conducted AD Muktar Mohamed and a copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Required - 1 Year

On October 9, 2025, at 12:45 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (ADMIN) Muktar Mohamed and explained the purpose of the visit. The facility is licensed to operate six (6) non-ambulatory of which one (1) maybe bedridden, and have a hospice waiver for six (6) residents. The facility is a single-story building located in a residential neighborhood. It consists of the following: three (3) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, attached 2-car garage, and an outside covered patio area. There is a unit attached on site that is dedicated to staff residency. and another unit that is attached to the facility that is dedicated as the licensee’s residency. Currently, there are no residents residing at the facility. LPA Kim toured indoor and outdoor of the physical plant with ADMIN Mohamed. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, and Resident Room 3. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 116.0 degrees F and 117.6 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The facility has one (1) fire extinguisher that is charged and mounted in the living area. All smoke/carbon monoxide detectors were operable. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the PUB475 posted in the living area measured at 8.5" X 11". LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). A working telephone (612-205-5094). First Aid Kit contained all the necessary elements. LPA conducted an audit staff files (S1) which was in order and complete. . A technical violation was assessed during the visit. LPA observed PUB475 posted in the living area measured at 8.5” x 11”. An exit interview was conducted, and a copy of this report and LIC9102 were provided to Administrator Muktar Mohamed.the state’s words, verbatim · CDSS document, Oct 9, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Lydia Martinez conducted this announced continuation of Pre-licensing visit to ensure the facility made the necessary corrections required from the Pre-licensing visit inspection on 08/08/2024. LPA Martinez met with Applicant Muktar Mohamed and both toured the facility, including the two apartments in question. Applicant needed a new Fire Clearance with updated facility sketch adding the two apartments that are attached to the facility structure. On 08/08/2024, LPA Martinez noted that the application’s approved Anaheim Fire Department (AFD) Fire Clearance did not match the structure. A two bedroom/one bathroom apartment and one bedroom/one bathroom apartment were not on facility sketch approved by AFD on 12/08/2023. Applicant submitted updated Floor sketch to CAB. Anaheim Fire Department conducted a second inspection and cleared the facility on 08/14/2024. With the above correction completed the facility's physical plant meets requirements of Title 22 Regulations. All items reviewed during the visit are in compliance. Facility appears to be ready for licensure based on LPA's evaluation. An exit interview was conducted with Applicant and a copy of this report was sent to the email on file.the state’s words, verbatim · CDSS document, Aug 22, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to this facility for the purpose of completing a Pre-licensing evaluation. LPA met with Applicants Muktar Mohamed. This is an initial application with no residents in care. The Application was submitted to Community Care Licensing on 11/08/2023. Facility is a single story, 4 bedroom, 3 full bathroom home with an attached 2 car garage. Facility also has an attached 2 bedroom, 1 bathroom apartment and an attached one bedroom 1 bathroom apartment. Facility will have live-in staff. The Fire Extinguisher is located in the room adjacent to the kitchen. Smoke detectors are hardwired throughout the facility. Carbon Monoxide was observed in hallway. Facility is secured by a fence around the property. Adequate seating is available in the dining room as well as the living room. Bedrooms are equipped with appropriate lighting, night stand and ample closet space. Applicant to purchase chairs for residents. Two bathrooms have wash basins and walk in showers; one has a bathtub. A supply of extra linen and towels were stored in closet. Facility has no food since there are no residents living at the facility. Applicant understands the importance of having a two day supply of perishables and seven day of non-perishable food at all times when residents are present. Stove, oven, refrigerator, dishwasher, microwave, washer, and dryer are clean and operational. There is a locked area for medications in a kitchen cabinet. Locked kitchen cabinet under the sink will be used for storing toxins, detergents, and cleaning supplies. Beds were made with appropriate linens. Hot water in bathrooms is within regulatory requirements. First Aid Kit observed contained all required items. The facility will have board games, go for walks, music therapy, exercise for activities. Facility has a covered patio. Applicant will purchase a patio table and chairs to accommodate residents and visitors. Side exit gates are unlocked. Component III was completed with Applicant during today’s inspection. Applicant will obtain liability insurance once the application is approved. (continued on LIC809C) A Fire Clearance was granted on 12/08/2023 for 5 non-Ambulatory, and 1 bedridden residents. During today's visit, LPA noted and Applicant explained that the Facility is the 4 bedroom, 3 full bathroom with the attached 2 car garage. The home also has a 2 bedroom, 1 bathroom apartment and a one bedroom 1 bathroom apartment; both attached to the facility. Home has one owner with three leases, including facility. Both apartments are not on the floor plan that was approved by the Anaheim Fire Department. Facility floor plan submitted with the application does not match the actual structure. LPA explained that clarification is needed before facility is ready for licensure based on inspection. LPA has contacted CAB. Applicant also to get landline installed, self latch spring for outside fence doors, chairs for resident bedrooms and patio table and chairs. An exit interview was conducted and a copy of this report will be sent to email on file.the state’s words, verbatim · CDSS document, Aug 8, 2024