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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320604
Report Date: 09/25/2025
Date Signed: 09/25/2025 03:15:07 PM

Document Has Been Signed on 09/25/2025 03:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PACIFIC CARE ASSISTED LIVINGFACILITY NUMBER:
198320604
ADMINISTRATOR/
DIRECTOR:		KHAN, ANWER MOHAMMEDFACILITY TYPE:
740
ADDRESS:406 W 234TH STTELEPHONE:
(310) 920-4696
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 0DATE:
09/25/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:13 PM
MET WITH:Anwer KhanTIME VISIT/
INSPECTION COMPLETED:
03:34 PM
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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

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PACIFIC CARE ASSISTED LIVING
FACILITY NUMBER: 198320604
VISIT DATE: 09/25/2025
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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

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PACIFIC CARE ASSISTED LIVING
FACILITY NUMBER: 198320604
VISIT DATE: 09/25/2025
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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

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PACIFIC CARE ASSISTED LIVING
FACILITY NUMBER: 198320604
VISIT DATE: 09/25/2025
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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 Continues

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5