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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881694
Report Date: 02/25/2025
Date Signed: 02/25/2025 11:09:58 AM

Document Has Been Signed on 02/25/2025 11:09 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SYCAMORE CANYON ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
331881694
ADMINISTRATOR/
DIRECTOR:		CHOUDRY, SAIFFACILITY TYPE:
740
ADDRESS:650 TACA STREETTELEPHONE:
(951) 275-7581
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY: 6CENSUS: 0DATE:
02/25/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Saif Choudry, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Licensee/Administrator Saif Choudry. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 11/22/2024 for a total capacity of six (6) with five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 1/23/2025 as stated Bedroom #1 is approved for bedridden client, Bedroom #2, #3, #4 is approved for non-ambulatory clients, garage is off limits. LPA Delgado observed the following:

Structure:
Facility was a one-story house with four (4) resident bedrooms, two and half (2.5) resident bathrooms, family room, kitchen, dining with a large office area setup . There was an attached three car garage in the front of the house.

Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.

Bedrooms:
Each resident bedroom #1 will accommodate bedridden resident, #2, #3 and #4 will accommodate any non-ambulatory resident. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.

Bathrooms:
Two and half (2.5) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap.
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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SYCAMORE CANYON ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 331881694
VISIT DATE: 02/25/2025
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(Continued from Page 1)

At 10:01 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 119 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were observed in laundry room that will be locked inaccessible to residents.

Living/Family room:
There was a living/family room for all clients and TV with streaming access.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence and hygiene supplies will be stored in the laundry room.

Yards/Outside:
Patio table and seating were observed in the backyard; shade is needed. There was a gate on the West side of the property with a self-latching hook. There is a pond 7' x 8' with no water and fire pit. All outdoor pathways were free of obstructions. There are three (3) window screens that are missing.

Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in all resident bedrooms and the main hallway. Obudsman poster and Let-Us-No poster observed.

(Continued on Page 3)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SYCAMORE CANYON ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 331881694
VISIT DATE: 02/25/2025
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(Continued from Page 2)

General items:
One (1) fire extinguisher were charged and located in the kitchen. Six (6) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked closet in the hallway. First Aid kit with required components and locked cabinet for medication storage was observed in the kitchen. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring.

Emergency water supply and the required 72-hour emergency food supply was observed. Component III was completed February 11, 2025 at Riverside RO with LPM Tricia Danielson.

Pre-Licensing is incomplete and the following corrections to be resolved by 3/4/2025:

obtain shade for outdoor patio
obtain PPE supplies
repair hole in dining area ceiling
remove 3 black cameras from interior areas
remove personal storage clothing
replace light bulb in foyer
replace 3 exterior window screens

An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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