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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881640
Report Date: 03/13/2025
Date Signed: 03/13/2025 11:19:05 AM

Document Has Been Signed on 03/13/2025 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A.R.K. RESIDENTIAL CARE, LLCFACILITY NUMBER:
331881640
ADMINISTRATOR/
DIRECTOR:
MAHMOUD, RABAHFACILITY TYPE:
740
ADDRESS:3530 TYCO DRIVETELEPHONE:
(432) 967-5376
CITY:RIVERSIDESTATE: CAZIP CODE:
92501
CAPACITY: 6CENSUS: 0DATE:
03/13/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee, Rabah MahmoudTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 03/13/25, Licensing Program Analyst (LPA) Debbie Palacios conducted an announced visit to complete the Pre-licensing inspection and met Licensee Rabah Mahmoud. Facility was approved to serve residents ages 60 and over; six (6) residents in which 3 (three) may be Non-ambulatory.

The facility is a five (5) bedroom, one (1) office room, one (1) staff bedroom and three resident (3) bedrooms, three (3) bathrooms, kitchen/dining area, one (1) living room area, laundry room and a backyard. LPA toured the interior and exterior areas of the facility. The following were inspected:

LPA observed resident bedrooms had the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, lighting, and emergency lighting. Resident bathrooms had clean appliances that were operating in safe and sanitary condition and the showers contained non-slip mats and grab bars.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. The knives and sharp objects were in a locked box in the kitchen cabinet. The facility's hot water temperature was recorded at 118F.

The washer and dryer are located in the laundry room and has a cabinet for the towels and bedding sheets. the detergents and cleaning supplies are in a locked cabinet in the garage. Client files, staff files, will be located in the staff office in a lock cabinet; medications will be locked in the hallway closet. The facility maintains an adequate supply of clean linen and personal hygiene supply. The facility does not have any bodies of water on the property. All passageways were free from obstruction. LPA observed two (2) charged fire extinguishers in the facility. The smoke detectors and carbon monoxide alarms were operational.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A.R.K. RESIDENTIAL CARE, LLC
FACILITY NUMBER: 331881640
VISIT DATE: 03/13/2025
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LPA observed required postings including the emergency/disaster plans, complaint procedures, and personal rights. The facility has an adequate area in the living room for activities; LPA observed board games and activity books. LPA observed a first aid kit with the required items and manual mounted on the living room wall. The facility has a central heating and air conditioning system installed with a central panel located in the hallway to control entire house. The facility has working telephone for resident use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA have determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations. Applicant Rabah Mahmoud completed the COMP III training on 03/11/25.

An exit interview was conducted, and this report was discussed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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