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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603755
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:00:57 PM

Document Has Been Signed on 05/28/2021 03:00 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:FAHIMA CARE HOME 1FACILITY NUMBER:
374603755
ADMINISTRATOR:RAUSHON AHMEDFACILITY TYPE:
740
ADDRESS:8554 CAPRICORN WAYTELEPHONE:
(858) 800-7455
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 5DATE:
05/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Raushon AhmedTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Natasha Persaud conducted a case management visit to follow-up on an incident reported to Community Care Licensing. LPA was greeted and allowed entry into the facility by Administrator, Raushon Ahmed and discussed the purpose of the visit.

Community Care Licensing was notified by facility representative that Resident #1 (R1) was missing from the facility on May 20, 2021. Staff went to wake R1 for breakfast and discovered R1 climbed out of their window. The facility followed their Absentee Notification Plan and contacted all required parties to include local law enforcement. Law enforcement located R1 and had R1 assessed at the hospital. R1 safely returned to the facility the same day without any injuries. Upon review of R1's Physician's Report, R1 is allowed to leave the facility unassisted. However, due to R1 climbing out of the window and not notifying staff they were leaving, administrator was concerned. Therefore, law enforcement was contacted.

During today's visit, LPA toured the facility, conducted a health and safety check of the residents, interviewed staff and residents, and requested facility records. No deficiencies were cited during today’s visit.

A copy of this report, LIC 811 Confidential Names List and Licensee Appeal Rights (LIC 9058) were provided to the Administrator via electronic mail. A reply E-mail or read receipt confirmation was requested from the administrator upon receipt of documents. [See LIC 811 Confidential Names List to identify Resident #1].
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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