A1 Residential Care Facility

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