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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006449
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:40:49 PM

Document Has Been Signed on 08/22/2024 12:40 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:
08/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Muktar MohamedTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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