Elderly Haven

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. Upon arrival, LPA was greeted by Care Staff Zenia Valdehueza. Administrator Mohammad Rahman joined the visit shortly afterward. LPA discussed the purpose of the visit with both staff. The facility license reflects a maximum capacity of six (6) non-ambulatory residents. LPA and Administrator Rahman toured the interior and exterior of the facility and inspected each room. The facility was bedrooms and livngroom room were observed to be clean, sanitary, and in good repair. Pathways were clear of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment for dining, laundry, visitation, meetings, and resident activities. Food supplies were inspected and found to include at least two (2) days of perishable items and seven (7) days of non-perishable items.. Cooking and dining equipment were available and operable. No toxic chemicals or poisons were accessible to residents. No pools or other bodies of water were observed on the premises. Carbon monoxide detectors, emergency lighting, and the facility telephone were operational. Fire extinguishers were serviced within the past twelve (12) months and first aid kits were complete. Required postings were observed in visible areas of the facility. (continued from LIc809) Staff interviewed reported adequate staffing and access to needed supplies. Staff demonstrated general knowledge of daily care routines; however, gaps were noted in medication procedures. Confidential resident and staff records were reviewed and were stored in locked areas. During the required annual visit, LPA reviewed resident records, medication storage, and staff training. LPA observed five (5) pre-poured medication in locked medication closet for residents #1- Resident #5 (R1–R5), Staff #1 confirmed during interview that staff pre-pour medications before administration. Further inspection of kitchen revealed that dishes were washed using soap and water only, with no sanitizing step. Rodent droppings as well as dead cockroaches were observed inside storage cabinets. During the inspection, LPA also observed staff rinsing contaminated linens outdoors using a garden hose. This practice does not meet infection control requirements for safe handling of soiled materials and poses an immediate health and safety risk. LPA observations further revealed the garage showed a bed, dresser, clothing, and personal belongings. Staff interviews did not confirm sleeping in the garage. However, the garage is not an approved living area under the facility’s fire clearance. Personal rights concerns were observed for residents R1–R3. Residents were observed partially undressed, wearing only briefs, or wearing shirts cut up the back. Care plans contained no documentation supporting the practice. Based on observations, interviews, and record review, deficiencies are cited today per California Code of Regulations, Title 22. Deficiencies are documented on the attached LIC 809-D pages. Plans of Correction (POCs) were jointly developed with the Administrator. An exit interview was conducted with Administrator Mohammad Rahman, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(31)(B) · Plan of correction due date: Sep 1, 2026

(B)The following food service requirements shall apply: (31)(B)B) In facilities not using mechanical means...as the addition of a sanitation agent to the final rinse water. This requirement was not met, as evidenced by: Based on observation and interview, the licensee failed to ensure that dishes and utensils were properly disinfected after handwashing for 5 of 5 residents (R1–R5). This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2026

Plan of correction: The licensee shall immediately implement an approved sanitizing method for all hand washed dishes. The licensee shall submit photos of properly set up sanitizing procedures by POC and a written plan confirming ongoing compliance and CCLD approved trainig by POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(27 · Plan of correction due date: Sep 1, 2026

87555 General Food Service Requirements(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met, as evidenced by: Based on observation and interview, the licensee did not ensure the kitchen and food service areas were maintained free of rodents droppngs for 5 of 5 residents (R1–R5). This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2026

Plan of correction: The licensee shall immediately clean and sanitize all contaminated kitchen surfaces and dishware, discard any items that cannot be safely sanitized, and contact a licensed pest control service. Proof of pest control service, sanitation logs, and photos of cleaned areas shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: Oct 1, 2026

87555(b)(18) – General Food Service Requirements (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met, as evidenced by: The licensee did not ensure food service personnel were adequately trained to meet the needs of 5 of 5 residents (R1–R5), which poses a potential health and safety risk to residents in care (R1-R5)the state’s words, verbatim · CDSS document, Aug 30, 2026

Plan of correction: The licensee shall ensure all food service staff receive training through an approved CCLD training vendor covering proper dish sanitizing procedures, food safety practices, vermin identification, and kitchen sanitation requirements. The licensee shall submit documentation of completed vendor provided training, including certificates and proof of completion, to LPA by POC Date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(1) · Plan of correction due date: Oct 1, 2026

The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.. This requirement was not met, as evidenced by: This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in 5 of 5 persons which poses a potential health and safety risk to residents in care (R1-R5)the state’s words, verbatim · CDSS document, Aug 30, 2026

Plan of correction: The licensee shall ensure all staff responsible for medication assistance receive training through an approved CCLD training vendor covering proper medication handling, administration from original pharmacy containers, and prohibitions against pre-pouring medications. The licensee shall submit documentation of completed vendor-provided training, including certificates and proof of completion, to LPA by POC Date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(a)(2)(A) · Plan of correction due date: Sep 1, 2026

(A) Surfaces such as floors, chairs, toilets.... These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement was not met, as evidenced by: Based on observation and interview, the licensee did not ensure infection control practices were maintained. Staff were observed rinsing soiled linens outside and draping them over bushes, which poses an immediate health and safety risk to 5 of 5 residents (R1–R5).the state’s words, verbatim · CDSS document, Aug 30, 2026

Plan of correction: The licensee shall immediately stop the practice of rinsing and draping soiled linen outside. The licensee agrees to obtain infection control training from an approved outside/CCLD vendor. All staff shall be re-trained on safe practices for handling of changing, transporting, and laundering contaminated resident items, including linens, clothing, and personal materials. The licensee shall submit schedule of vendor-provided training to LPA by POC date and Provide proof of training 10-1-2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307 · Plan of correction due date: Sep 1, 2026

87307Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement was not met, as evidenced by: Based on observation, the licensee did not ensure living accommodations matched the approved facility function. Staff were observed using the garage as a sleeping area, although the garage is not approved for habitation under the facility’s fire clearance. This poses a potential health and safety risk for 5 of 5 residdentsthe state’s words, verbatim · CDSS document, Aug 30, 2026

Plan of correction: Licensee shall immediately stop the practice of staff sleeping in the garage. All staff shall sleep only in areas approved under the facility’s fire clearance. Licensee shall submit photos showing the garage is used as store room and office only by POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 1, 2026

87468.1(a)(1) – Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met, as evidenced by: Based on observation and interview, the licensee did not ensure residents were accorded dignity. Residents were observed either partially undressed, in briefs only, or wearing altered clothing cut up the back, which poses an immediate personal rights risk for 3 of 5 residents (R1–R3).the state’s words, verbatim · CDSS document, Aug 30, 2026

Plan of correction: The licensee shall immediately stop the practice of using cut shirts and ensure all residents are offered dressing in appropriate, intact clothing that protects dignity. All staff will receive personal-rights training through an approved CCLD vendor. Proof of training and confirmation that residents are properly dressed will be submitted to LPA by POC date

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Other visit. LPA was greeted and allowed entry into the facility by Staff, Virgnia Cadalzo. Staff, Zenia Valdehueza was also present. Licensee, Mohammad Rahman arrived during the visit. On 03/27/26, the licensee contacted LPA stating they admitted their fourth (4) resident on hospice. The facility has a hospice waiver for three (3). The licensee stated they were waiting for over one (1) month for approval from the department. However, the licensee submitted a hospice waiver increase but it was not compliant with Title 22 Regulations. Therefore, LPA provided guidance to the licensee multiple times. Not until 03/27/26, did the licensee submit a compliant request for a hospice waiver increase for the department to review. The licensee did not comply with law and await approval for their prospective resident. In addition, on 08/12/25, the facility was issued deficiencies during an Annual Required Inspection. The deficiencies were not reviewed and/or cleared at that time. Therefore, today, LPA conducted a review of the items cited. Some deficiencies have been corrected. The deficiency regarding both showers requiring repair, as not been corrected. Both showers have peeling paint, dirty crevices, and present as a sanitary hazard and physical hazard to residents. Deficiencies were issued for a hospice violation and showers requiring repair. An exit interview was conducted with Licensee, Mohammad Rahman to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 11, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(a) · Plan of correction due date: Jul 9, 2026

Hospice Care Waiver. In order accept or retain terminally ill residents...the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver... request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. Based on interviews and record review, the licensee did not obtain a hospice waiver approval for 1 out of 4 [R1] residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: Licensee submitted a compliant hospice waiver. POC corrected.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jul 9, 2026

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not ensure the facility was in good repair for 4 out of 4 residents [R1-R4], which poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: Licensee will repair both showers to ensure they are safe by POC due date.

Allegation investigated: Neglect, resulting in delayed medical care Staff did not meet resident's hygiene needs

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude a complaint investigation regarding the above mentioned allegations. LPA met with Licensee, Dr. Mohammad Rahman . During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged Resident #1 (R1) was neglected, resulting in delayed medical care and staff didn’t meet R1’s hygiene needs. R1’s Preplacement Appraisal dated 12/16/25 indicated R1 was unable to get up due to severe pain. It also stated R1 always wanted to call 911 when in pain and wanted to receive their hip surgery. The report reflected R1 required assistance with bathing, hair care, and personal hygiene. It was reported that R1 was transferred on 12/17/25 from a Skilled Nursing Facility (SNF) to this facility, while awaiting hip replacement surgery. On 12/20/25, R1 called 911 due to hip pain. Staff reported not being aware of the call and paramedics suddenly arrived at the facility. Continued on LIC 9099C. Unsubstantiated Staff stated they were advised by the paramedics that R1 required permission due to the resident contacting 911 themselves. Staff called R1’s responsible party to obtain permission but could not get hold of them. R1’s responsible party reported receiving calls from an unknown number, and the person calling was speaking a different language. Therefore, no contact with facility staff was made. Staff explained that the paramedics did not transport R1 to the hospital. The following day, R1’s responsible party was made aware R1 was still having pain and arranged transport to the hospital. R1 was experiencing pain upon admission to the facility and awaiting the hospital to schedule their hip surgery. A review of facility records reflected on 12/17/25, R1 signed the facility’s Consent For Emergency Medical Treatment form. The form provides consent on behalf of the facility for the residents. R1 reported they called 911 because they were in pain. R1 admitted they didn’t alert staff that they contacted 911. R1 stated they explained to the paramedics they were in pain and awaiting surgery. The paramedics stated there wasn’t a medical need to take R1 to the hospital. R1 said the paramedics explained the transport was costly. Therefore, that was the reason staff contacted R1’s responsible party to clarify if the responsible party would pay for the transport. R1 declined the transport due to the paramedics stating there wasn’t a medical need and the cost being high. The paramedics are trained health professionals and make decisions on transporting individuals requiring care. The paramedics did not observe a medical need to transport R1. Conflicting statements were made regarding delayed medical care. It was also alleged that staff did not meet R1’s hygiene needs by not providing grooming/hygiene and assistance with brushing R1’s teeth. It was also reported that R1 was not clean when arriving at the facility from the SNF. In addition, R1’s responsible party asked the facility staff to wash R1's feet, shave their face, and do a general clean up. The following day, R1 was not provided with their hygiene needs, as requested. Staff interviews stated R1 was at the facility for a few days but was kept clean and they were not asked to clean or shave R1. Staff added they ensure residents receive their hygiene needs. Staff also recalled R1 as being independent with brushing their teeth. R1 confirmed they are able to brush their own teeth, if they are provided with their items. R1 also stated they were at the facility briefly but were kept clean by staff. Conflicting statements were made regarding hygiene needs being met. Continued on LIC 9099C. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Dr. Mohammad Rahman via email.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 08-AS-20251226115615

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Natasha Persaud conducted a Case Management - Deficiencies visit. LPA identified herself and discussed the purpose of the visit with Staff, Priscilla Cardozo. LPA spoke with Licensee, Mohammad Rahman via telephone, while at the facility. Administrator, Syeeda Seli Akhter-Rahman arrived during the visit. Today, LPA was at the facility for a complaint investigation. LPA observed Resident #1 (R1) had a bubble pack of medication, milk of magnesia and a bag of other medications stored in their room. R1's medications are locked in the facility's centrally stored medication cabinet. However, R1 had possession of those listed items. The Licensee stated they were not aware R1 had medications in their room. LPA requested R1's records but staff was unable to locate the file. LPA also requested a former resident's file, but staff were unable to locate it. Deficiencies were observed and cited on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Syeeda Seli Akhter-Rahman whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jan 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 6, 2026

Incidental Medical and Dental Care: “(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met, as evidenced by: Based on observations, the licensee did not ensure medications were inaccessible to 5 out of 5 [R1-R5] residents, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: The administrator and all staff, including the licensee will attend vendor training regarding medications being locked/inaccessible to residents. The administrator will provide proof of scheduled training date by POC due date, tomorrow, and submit proof of training within 2 weeks.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Jan 9, 2026

Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not maintain records for 1 out of 5 [R1-R5] residents and a former resident, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: The administrator stated they will ensure the records are accurate and available at the facility for review. Administrator and licensee will attend training on resident records and submit proof of training by POC due date.

Allegation investigated: Staff yelled at resident in care

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Staff, Revelyn Ibera. Licensee, Mohammad Rahman and Administrator, Syeeda Seli Akhter-Rahman arrived during the visit. During today's visit, LPA briefly toured the facility, reviewed records, interviewed staff and residents. It was alleged staff yelled at resident in care. It was reported a male staff yelled "shut up" at a resident due to the resident asking repeated questions. The resident that was allegedly yelled at has a Major Neurcoginitive Disorder. The resident was interviewed but due to the cognitive impariment, the interview was unsuccessful. Interviews with staff revealed they have not witnessed any caregivers yelling at staff or telling them to shut up. Residents interviewed also confirmed they have not witnessed staff yell or tell any residents to shut up. A review of records indicated the male staff member has receivd abuse training on file. Outside sources were interviewed and also stated they have not witnessed staff yelling or tell residents to shut up.Continued on an LIC 9099C. Unsubstantiated During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Mohammad Rahman whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 08-AS-20250829161121

Type of visit: Office

Licensing Program Analyst (LPA), Natasha Persaud conducted an office meeting with Regional Manager, Jerry Romero, Licensing Program Manager, Lizzette Tellez, Licensing Program Analyst, Ramin Hashemi, Licensee, Dr. Mohammad Rahman and Administrator, Syeeda Seli Akhter-Rahman. Today's meeting addressed a complaint filed against the facility regarding absence of supervision and medications not being centrally stored. On 08/26/25, it was reported staff were absent from the facility and medications were left on the table, accessible to residents. On 08/26/25, the Department issued substantiated findings, issued deficiencies and civil penalties to address non-compliance. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Dr. Mohammad Rahman whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 27, 2025

Allegation investigated: -Licensee had absence of supervision at facility. -Licensee did not ensure medications were secured/locked.

Licensing Program Analysts (LPA) Dang Nguyen and Ramin Hashemi conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Maribel Coloma. LPAs then met with Licensee Dr. Mohammad Rahman, who arrived later during the visit. The Complainant alleged that Licensee had an absence of supervision at the facility, and that Licensee did not ensure that medications were secured/locked. CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of pertinent staff, residents, and outside sources. The Department also reviewed relevant care records. [CONTINUED ON LIC 9099] Substantiated [CONTINUED FROM LIC 9099] Interviews aligned to show that during the morning of 08/26/2025: Staff #1 (S1) was the sole employee on duty and left the premises. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] There was a period of at least one (1) hour when there were residents in care at the facility without on-duty staff present. While S1 was away, medications for one (1) resident were temporarily left atop the dining room table in plain view, unsecured and unlocked. Based on interviews, a preponderance of evidence exists to show Licensee had an absence of supervision at the facility, and that Licensee did not ensure that medications were secured/locked. Both allegations were therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Since one of the deficiencies pertains to absence of supervision, a Zero Tolerance Violation Civil Penalty of $500 was also assessed/charged (refer to the attached LIC421-IM page). Since the medication deficiency is a repeat violation within a twelve (12) month period, a Repeat Violation Civil Penalty of $250 was also assessed/charged (refer to the attached LIC421-FC page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee Dr. Mohammad Rahman, to whom a copy of this report, the LIC 9099-D page, the LIC421-IM page, the LIC421-FC page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 08-AS-20250826140115

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 26, 2025

87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that facility personnel at all times were sufficient in numbers to provide the services necessary to meet the needs of 4 of 4 residents (R1 through R4). This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Upon LPAs’ arrival, they verified that Licensee had staff present and caring for residents, resolving the immediate risk. Licensee agreed to perform written corrective action/counseling with S1 to reinforce to them that they shall not leave residents unsupervised, unless/until relieved by an on-duty coworker. Licensee also agreed to lead an inservice training with the larger staff team on the same topic and the importance of timely communicating tardiness to facility management. Licensee agreed to E-mail a copy of the corrective action document and the training sign-in sheet to LPA Nguyen, by 09/26/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87645(h)(2) · Plan of correction due date: Aug 26, 2025

87465 Incidental Medical and Dental Care: “(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that centrally stored medications were kept in a safe and locked place that is not accessible to persons other than employees responsible for them. This posed an immediate health and safety risk to 4 of 4 residents (R1 through R4) in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Upon LPAs’ arrival, the medications in question had been secured, and LPAs saw that the facility’s medication cabinet was locked, resolving the immediate risk. Licensee agreed to perform written corrective action/counseling with S1 to reinforce to them that they shall not leave residents’ medications unlocked/unsecured. Licensee also agreed to lead an in-service training with the larger staff team on the same topic. Licensee agreed to E-mail a copy of the corrective action document and the training sign-in sheet to LPA Nguyen, by 09/26/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Revelyn Ibera. Licensee, Mohammad Rahman and Administrator, Syeeda Seli Akhter-Rahman. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was sanitary, but needs repair. The fridge and freezer had dead insects and debris. Foods were not labeled and dated. The hot water for the sink in restroom #1 is not working, the shower mat was molded, the shower needs repair as far as the walls and crevices. Restroom #2's ceiling fan is making a loud noise and the shower walls and crevices needs to be repaired. Licensee was advised an updated dementia plan was needed along with an addendum to the plan of operation to include video surveillance. Disaster drills are being conducted but not documented correctly. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and toilets, and showers were in working order. However, the sliding door screens are not flush to the frames/bases, all need to be replaced or repaired. There were extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 110 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, but not stored in locked areas. There was insulin and suppositories in the fridge, and the garage had medications belonging to a caregiver, not locked. The licensee explained the insulin was in an unidentified package, made unknown it was insulin and is not being used. Also, the suppositories are not being used. The licensee explained the residents are monitored and do not enter the kitchen area, removing any immediate threat. LPA was able to confirm the medications were not noticeable and had to be pointed out by staff. Also, there were expired medications belonging to residents that no longer resided in the facility but the cabinet was locked. No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was incomplete. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. The licensee explained the residents and still working with the families to complete the required documentation. Confidential records were stored in locked areas. The licensee requested to increase their bedridden status. LPA printed the application and assisted with completion. Deficiencies were observed or cited during today's annual inspection, along with Technical Advisories. An exit interview was conducted with Licensee, Mohammad Rahman to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Revelan Ibera. Licensee, Syeeda Akhter-Rahman arrived during the visit. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The sink in bathroom #2 has a leak. However, the licensee has already contracted an outside source for repairs. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 106 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were toxic chemicals/poisons accessible to residents. LPA observed chemicals were accessible under the kitchen sink and in the garage. There was a lock on the kitchen cabinet under the sink but it was not locked. Medications were labeled, as required but not locked. A lock was present on the medication closet but it was not locked. The facility has a resident that walks around the facility independently. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Continued on an LIC 809C. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Also, required staff training was not documented. Confidential records were stored in locked areas. Deficiencies were observed or cited during today's annual inspection. Also, Advisory Notes were issued. An exit interview was conducted with the licensee to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 28, 2024