Montoak One

Type of visit: Required - 1 Year

On 03/26/2026 at 12:00 pm, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Montoak One Facility. LPA Calderon was allowed entry into the facility by Administrator Najma Shaheen. The licensee has a license to serve (6) elderly residents ages 59 and older. Currently, there are (6) residents residing in the facility age 59 or older. LPA Calderon explained to Administrator Najma Shaheen, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Six (6) client service records, six (6) client medication records, four (4) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 01/05/2026. The one-story residential home consists of five (5) client bedrooms, two (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the kitchen area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Kitchen hot water temperature properly measured at 113 degrees Fahrenheit. Facility one (1) Carbon Monoxide and seven (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility one (1) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knives are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. A working landline phone was operational. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Six (6) client files were reviewed and found to be complete. LPA Calderon reviewed six (6) resident medications, and they were all found to be administered according to doctor's orders. Four (4) staff files were checked, and they have the required documents. LPA Calderon noted the Administrator Najma Shaheen Certification # 7013300740 expiration date of 04/12/2027 was valid at time of visit. The facility does NOT handle clients’ money/cash resources, and a NO Surety bond is needed. Commercial General Liability Policy #ISCAH010000033400 policy period from 02/20/2026 to 02/20/2027 underwritten by Certain Underwriters at Lloyds Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Najma Shaheen to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 05/10/2026. All the required documents are posted in the facility in a clearly visible area. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Najma Shaheen.the state’s words, verbatim · CDSS document, Mar 26, 2026

Allegation investigated: Staff illegally evicted a resident in care. Staff are serving food that is not of quality to residents in care. Facility did not ensure that staff received training. Staff are leaving residents unattended Staff withheld resident's funds. Staff did not keep facility free of clutter. Staff are not providing activities for residents in care. Staff made alterations to the facility without notifying licensing. Staff did not maintain a comfortable temperature for residents in care.

On 01/15/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Montoak One and was greeted by Administrator Najma Shaheen (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, residents R1-R4. LPA Calderon obtained the following records: LIC500(dated 01/13/2026), Incident report (dated 11/29 /2025,01/03/2026 and 01/09/2026), Physician report (dated 10/21/2025), training for licenses and staff, refund calculation (dated 01/09/2026), admission agreement (dated 11/03/2025), UCLA medical records (dated 10/10/2025), menu Calander, activity calendar for R1. The investigation revealed the following: Unsubstantiated The investigation revealed the following: Regarding the Allegation: Staff illegally evicted a resident in care. This complaint alleged that the facility evicted R1 from the facility. Records review indicate the following: Reviewed incident report (dated 11/29/2025), report indicates that R1 was aggressive with staff and wanted to leave the facility. R1 was transported to the hospital. 01/03/2026 R1 was aggressive and was transported to the hospital for psychiatric evaluation and treatment. 01/09/2026 hospital social worker called and advised that R1 requires a higher level of care due to safety concerns. Interviews indicate the following: S1 indicates that R1 was taken to the hospital and evaluated by social workers and doctors as needing higher level of care. S1 indicates that R1 never returned to the hospital and no notice of eviction was ever given. 3 out of 3 staff deny the allegation. R1 no longer lives at the facility and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff illegally evicted a resident in care” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are serving food that is not of quality to residents in care. This complaint alleged that the facility does not serve quality food. LPA Calderon toured the facility and noted staff had served breakfast to residents and lunch. LPA Calderon noted 2-day supply and 7-day supply of food in kitchen. LPA Calderon did not notice any residents refusing or not eating the food. Records reviewed indicate the following: LPA Calderon reviewed the meal plan for the month. Interviews indicate the following: S1 indicates that S1 purchases quality food that the residents love to eat. S1 indicates that staff serve quality food to residents in care. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are serving food that is not of quality to residents in care” is found to be UNSUBSTANTIATED. Regarding the Allegation: Facility did not ensure that staff received training. This complaint alleged that the facility staff do not train staff that work for the facility. Records reviewed indicate the following: Reviewed training certificate for S1-S3. Training provided to staff CPR/First aid, Medication assistance. Interviews indicate the following: S1 indicates that the facility provides training to staff on an annual basis. S1 indicates that all staff must have training to work for the facility. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives at the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility did not ensure that staff received training” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are leaving residents unattended. This complaint alleged that the facility does not have staff working weekends. LPA Calderon toured the facility and noted staff working in both homes. Records reviewed indicate the following: LPA Calderon reviewed the LIC500 and noted staff working weekends. LPA Calderon noted staff working in the facility. Interviews indicate the following: S1 indicates that S1 has staff working every day. S1 indicates S1 family lives at the facility and can cover for staff that call in sick. S1 indicates that residents never go unsupervised. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are leaving residents unattended” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff withheld residents funds. This complaint alleged that the facility does not refund R1 money. Records reviewed indicate the following: LPA Calderon reviewed refund calculation (dated 01/09/2026), R1 refund check was given to R1 family. Interviews indicate the following: S1 indicates that R1 refund check was issued on 01/09/2026 and R1 family signed for the check. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff withheld residents funds” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not keep facility free of clutter. This complaint alleged that the facility does not keep the facility clean and free of clutter. LPA Calderon toured the facility and noted staff have been cleaning. LPA Calderon noted the facility was clean and free of clutter. Interviews indicate the following: S1 indicates that staff clean every day and make sure that the facility is clean and free of clutter. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not keep facility free of clutter” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not providing activities for residents in care. This complaint alleged that the facility does not provide activities for residents. LPA Calderon toured the facility and residents reading, watching tv and outside walking. Records reviewed indicate the following: LPA Calderon reviewed the activity calendar for the month. Interviews indicate the following: S1 indicates that residents have activities to do every day. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not providing activities for residents in care” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff made altercations to the facility without notifying licensing. This complaint alleged that the facility has residents living in the garage. LPA Calderon toured the facility and did not note any garage or staff or residents sleeping or living in an area not designed for people. LPA Calderon noted 6 residents’ rooms in the facility. Interviews indicate the following: S1 indicates that there is no garage and no residents are sleeping in an area not for residents. S1 indicates that each resident has a room. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff made altercations to the facility without notifying licensing” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not maintain a comfortable temperature for residents in care. This complaint alleged that the facility does not have AC for the facility. LPA Calderon toured the facility and noted heat in the AM and AC in the PM> LPA Calderon noted the facility had a comfortable room temperature. Interviews indicate the following: S1 indicates that the facility room temperature is controlled. 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not maintain a comfortable temperature for residents in care” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Najma Shaheen (S1).the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20260106154619

Allegation investigated: Staff do not provide adequate care and supervision. Staff do not communicate effectively with the residents. Staff are not properly trained.

On 01/14/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Montoak One and was greeted by Administrator Najma Shaheen (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, residents R1-R4. LPA Calderon obtained the following records: LIC500(dated 01/13/2026), Incident report (dated 12/20/2025,12/29/2025 and 01/04/2026), Physician report (dated 06/10/2024), training for licenses and staff for R1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff do not provide adequate care and supervision. This complaint alleged that the facility staff did not have staff working on 01/04/2026. LPA Calderon and S1 toured the facility. LPA Calderon noted resident coming and going. LPA Calderon noted 3 staff working and there were no negative interactions between staff and resident noted. Records review indicate the following: Reviewed incident report (dated 01/04/2026), report indicates that R1 complained of not feeling safe and called the police. Police arrived and did not find any issues. The Physician report (dated 06/10/2024) indicates that R1 has no cognitive health issues. LIC500 indicates that there is day, night and weekend staff working. Interviews indicate the following: S1 indicates that there are 2 staff that work in the front house and 1 staff that work in the back house. S1 indicates that S1 family live on the property for any issues. 3 out of 3 staff deny the allegation. R1 indicates that on weekends there are no staff living or working in the back house. R1 indicates that R1 did not feel safe and called the police. R1 indicates that the police did not find any staff working. R2 could not be interviewed as R2 moved out of the facility. 2 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not provide adequate care and supervision” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not communicate effectively with the residents. This complaint alleged that the facility staff did not speak English to residents in care. LPA Calderon toured the facility and noted staff speaking to residents in English. LPA Calderon did not notice any negative interactions between staff and residents. Records reviewed indicate the following: Reviewed incident report (dated 12/20/2025, 12/29/2025 and 01/04/2026), reports indicate that R1 had combative relations with staff. Interviews indicate the following: S1 indicates that R1 was combative with staff and advised S1 that R1 did not feel safe in the facility. S1 indicates that staff speak English and communicate with residents in care. S2-S3 interviewed with LPA Calderon in English. S2-S3 primary language is Spanish. 3 out of 3 staff deny the allegation. R1 indicates that the staff hired by the facility do not speak English and cannot communicate with residents in care. R2 cannot be interviewed due to R1 being moved to another facility. 2 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not communicate effectively with the residents” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not properly trained. This complaint alleged that the facility staff do not train staff that work for the facility. Records reviewed indicate the following: Reviewed training certificate for S1-S3. Training provided to staff CPR/First aid, Medication assistance. Interviews indicate the following: S1 indicates that the facility provides training to staff on an annual basis. S1 indicates that all staff must have training to work for the facility. 3 out of 3 staff deny the allegation. R1 indicates that staff are not trained and should not take care of residents. R2 cannot be interviewed due to R1 being moved to another facility. 2 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not properly trained” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Najma Shaheen (S1).the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 11-AS-20260105121431

Type of visit: Required - 1 Year

On 05/01/2025 at 10:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Montoak One Facility. LPA Calderon was allowed entry into the facility by Administrator Najma Shaheen. The licensee has a license to serve (6) elderly residents ages 59 and older. Currently, there are (6) residents residing in the facility age 59 or older. LPA Calderon explained to Administrator Najma Shaheen, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Six (6) client service records, six (6) client medication records, three (3) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 04/10/2025. The one-story residential home consists of five (5) client bedrooms, two (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the kitchen area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Kitchen hot water temperature properly measured at 113 degrees Fahrenheit. Facility one (1) Carbon Monoxide and seven (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility one (1) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. A working landline phone was operational. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Six (6) client files were reviewed and found to be complete. LPA Calderon reviewed six (6) resident medications, and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Najma Shaheen Certification # 6043760740 expiration date of 04/12/2025 was NOT valid at time of visit. The facility does NOT handle client's money/cash resources, and a NO Surety bond is needed. Commercial General Liability Policy #001519281 policy period from 01/30/2025 to 01/30/2026 underwritten by James River Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Najma Shaheen to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 05/10/2025. All the required documents are posted in the facility in a clearly visible area. LPA Calderon advised the Administrator Najma Shaheen to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Najma Shaheen.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Post Licensing

On 06/13/2024 at 10:20 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Post licensee inspection visit at the Montoak One Facility. LPA Calderon was allowed entry into the facility by Administrator Najma Shaheen. Administrator Najma Shaheen asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The licensee has applied for a license to serve (6) elderly residents ages 59 and older. Currently, there are (4) residents residing in the facility age 59 or older. LPA Calderon explained to Administrator Najma Shaheen, the purpose of the Post licensee Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: (4) resident service records (reviewed personnel policies, abuse reporting procedures and in-service training and medication procedures for 4 residents), (4) resident medication records, (3) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 05/01/2024. The one-story residential home consists of (5) resident bedrooms, (2) resident bathrooms, living room, kitchen, attached garage with washer and dryer/ storage area, backyard with NO table and chairs were noted. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water supply is found in the bedrooms. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 105 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 108 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (1) carbon Monoxide and (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility (1) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Three (4) resident files were reviewed and found to be complete. LPA Calderon reviewed (4) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Najma Shaheen Certification # 6043760740 expiration date of 04/12/2025 was valid at time of visit. The facility does NOT handle resident's money/cash resources and a Surety bond is not needed currently. All the required documents are posted in the facility in a clearly visible area to include a copy of the General Liability policy James River Insurance Company #001519280 which was valid policy at time of inspection (01/30/2024 to 01/30/2025. LIC500 all 3 staff members are associated to the facility. LPA Calderon requested a copy of the LIC308 dated 03/18/2024, designate name Najma Shaheen. During the visit, LPA Calderon observed the physical plant & environment safety practices. LPA Calderon observed the facility has a thirty-day supply of Personal Protective Equipment (PPE). LPA Calderon advised the Administrator Najma Shaheen to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe NO deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Najma Shaheen.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Prelicensing

On 3/6/2024 Licensing Program Analyst (LPA) Troy Watson and Licensing Program Manager(LPM) Stephanie Cifuentes conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensee: Najma Shaheen The licensee has applied for a license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (6) ambulatory only residents. A tour was conducted of the kitchen, dining room, living room, (5) bedrooms, and (2) bathrooms. The following was observed during this visit: MEDICATIONS There is a locked centralized storage area for Resident medications in facility kitchen. PHYSICAL PLANT Facility is clean, sanitary and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches and areas of potential hazard are well-lit. Seven interconnected and hardwired smoke alarms were tested and operate properly. Continued on 809-C BEDROOMS There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair for each client and at least one (1) nightstand per two (2) clients. BATHROOMS There are two (2) toilets and washbasin per six (6) clients, family, and personnel. There are (2) shower or bathtub per ten (10) clients, family, and personnel. The hot water temperature measured at 111° Fahrenheit. The bathrooms are located near the client’s bedrooms. SUPPLIES There are clients’ personal hygiene supplies to include soap, toothpaste, toilet paper. There is a sufficient supply of clean linens to permit weekly changing or more of top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer and refrigerator are the appropriate temperature. A seven (7) day supply of non-perishable food is present. There is enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. Continued on 809-C ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. During this pre-licensing inspection, LPA did not find corrections are needed. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available 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 their assigned CAU Analyst. Exit interview conducted with Najma Shaheen/Administrator-Licensee.the state’s words, verbatim · CDSS document, Mar 6, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Najma Shaheen, admin/applicant Interview Method: Telephone interview On February 13, 2024, 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 following areas: 1. Facility operation: License type, client/resident populations, and program 2. General Provisions; staffing requirements and training 3. Staffing requirements and pre-licensing readiness 4. Reporting Unusual Incidents/Admin Requirementsthe state’s words, verbatim · CDSS document, Feb 13, 2024