<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603755
Report Date: 05/09/2025
Date Signed: 05/09/2025 04:18:28 PM

Document Has Been Signed on 05/09/2025 04:18 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:FAHIMA CARE HOME 1FACILITY NUMBER:
374603755
ADMINISTRATOR/
DIRECTOR:		RAUSHON AHMEDFACILITY TYPE:
740
ADDRESS:8554 CAPRICORN WAYTELEPHONE:
(858) 800-7455
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 6DATE:
05/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator, Raushon AhmedTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Petra Galindez. The Licensee, Fahima Nazreen and Administrator, Raushon Ahmed arrived during the visit.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 115 F..

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Confidential records were stored in locked areas. Resident #4 (R4) has a wound on the back of their neck. R4 was laying in bed with a sweatshirt that was cut in half up the back of the sweatshirt and draped across the front of R4. LPA explained residents should be accorded dignity and wear clothing in good condition. Continued on an LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Natasha Persaud
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
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 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: FAHIMA CARE HOME 1
FACILITY NUMBER: 374603755
VISIT DATE: 05/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator added it was easier for staff to care for the wound by the sweatshirt being cut open, making the wound accessible for staff. In addition, staff were opening resident bedroom doors without knocking. LPA advised and observed staff enter without knocking after being advised of resident personal rights. Staff were interviewed and unable to answer some of LPA's questions. The administrator was advised vendor training is now required for staff regarding annual training.

Deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator, Raushon Ahmed and Licensee, Fahima Nazreen and a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Natasha Persaud
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/09/2025 04:18 PM - It Cannot Be Edited


Created By: Natasha Persaud On 05/09/2025 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: FAHIMA CARE HOME 1
FACILITY NUMBER: 374603755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)
Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and interviews, the licensee did not ensure staff are treating 4 out of 6 [R1, R2, R4, R6] residents, which posed a potential personal rights risk to residents.
POC Due Date: 06/06/2025
Plan of Correction
1
2
3
4
Administrator agreed to In-Service the staff on personal rights and provide proof of training by POC due date.
Type B
Section Cited
CCR
87506(a)

Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and record review the licensee did not ensure resident records complete for 2 out of 6 [R2 and R6] residents, which posed a potential health, safety, and/or personal rights risk to residents.
POC Due Date: 06/06/2025
Plan of Correction
1
2
3
4
Administrator stated they will complete and submit all resident records by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Natasha Persaud
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4