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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701655
Report Date: 11/20/2025
Date Signed: 11/20/2025 12:01:23 PM

Document Has Been Signed on 11/20/2025 12:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALI SENIOR LIVINGFACILITY NUMBER:
342701655
ADMINISTRATOR/
DIRECTOR:		ALI, SAIMAFACILITY TYPE:
740
ADDRESS:5865 AMBLER STREETTELEPHONE:
(916) 337-5458
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 0DATE:
11/20/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Ali SaimaTIME VISIT/
INSPECTION COMPLETED:
12:21 PM
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On 11/20/2025, Licensing Program Analyst (LPA) Pang Lee arrived, announced, to conduct a Pre-Licensing Visit. LPA met with Applicant Saima Ali and Mobussar Ali and explained the purpose of the visit. This Pre-Licensing inspection was conducted due to a change of ownership. The current census is zero. A brief interview with Applicant Saima Ali and Mobussar Ali was conducted.

The facility is a single-story home with a fire clearance for six (6) non-ambulatory residents. Upon arrival, LPA observed a ramp at the front entrance that did not have handrails. LPA advised the applicant that a sturdy handrail should be installed for resident health and safety. Dining areas, living areas, and other resident-use areas were toured. LPA reviewed the facility sketch dated 10/09/2025 and confirmed that it aligns with the physical plant, both interior and exterior. LPA observed that the Complaint Poster (Pub 475) was not in the required size of 20" x 26" and informed the applicant of the size requirement. A kitchen tour was conducted. LPA observed a sufficient supply of food, including at least a 2-day supply of perishable items and a 7-day supply of non-perishable items. Knives were locked and inaccessible to residents. The pantry was also inspected; additional non-perishable food supplies were stored there. A locked centrally stored medication cabinet was located inside a kitchen cabinet. The First Aid Kit was present and contained all required components. The smoke and carbon monoxide detectors are in compliance with fire safety. A fire extinguisher was located in the dining room and is serviced and valid through 10/30/2026.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALI SENIOR LIVING
FACILITY NUMBER: 342701655
VISIT DATE: 11/20/2025
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LPA observed that the dining room entrance leading to the common area contains a step, and the turn into the common area measures 35 inches. LPA advised that this area should be leveled to ensure wheelchair accessibility. A tour of the garage was conducted. The laundry units are located in the garage, and laundry detergent, bleach, and cleaning supplies were secured and inaccessible to residents. Four resident bedrooms were toured. Furniture and furnishings were in good repair. The entry door to Bedroom #1 measured 29.5 inches. LPA advised the applicant that bedrooms must be large enough to allow easy passage and provide comfortable living accommodations. Resident bathrooms were inspected, and hot water temperature was tested in a resident bathroom. The hot water measured 105.8 degrees Fahrenheit. The facility temperature measured at 72 degrees Fahrenheit. The exterior of the facility was in good repair with no observed hazards. The perimeter fence was stable, and gates were functioning properly.

The following corrections will need to be completed before being licensed:

• Install handrails on the front entry ramp
• Level the step between the dining area and the common area to allow accessible passage
• Post Pub 475 in the required size of 20" x 26"

Due to the observations made during this Pre-Licensing visit, the applicant has not passed the Pre-Licensing component of the application process. The applicant will make the required corrections and notify LPA once they have been completed. An exit interview was conducted, and a copy of this report was provided to the applicant.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
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