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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006449
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:14:44 PM

Document Has Been Signed on 08/08/2024 12:14 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A1 RESIDENTIAL CARE FACILITYFACILITY NUMBER:
306006449
ADMINISTRATOR/
DIRECTOR:		MOHAMED, MUKTARFACILITY TYPE:
740
ADDRESS:2241 E ALDEN AVETELEPHONE:
(612) 205-5094
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 0DATE:
08/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Muktar MohamedTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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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)
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A1 RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 306006449
VISIT DATE: 08/08/2024
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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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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