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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603755
Report Date: 04/21/2022
Date Signed: 04/27/2022 08:26:00 AM

Document Has Been Signed on 04/27/2022 08:26 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, 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: 4DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:03 PM
MET WITH:Administrator, Raushon AhmedTIME COMPLETED:
05:16 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced annual required licensing inspection. LPA was greeted and allowed entry into the facility by Staff, Zoraida Soriano. LPA met with Administrator, Raushon Ahmed. LPA stated purpose of today’s visit, to verify compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA conducted a tour of the facility and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided consultation, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

No deficiencies were observed during today’s visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Administrator, Raushon Ahmed whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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