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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603755
Report Date: 01/05/2026
Date Signed: 01/05/2026 07:11:09 PM

Document Has Been Signed on 01/05/2026 07:11 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: 3DATE:
01/05/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Staff, Petra GalindezTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted a Case Management - Deficiencies visit. LPA was greeted and allowed entry into the facility by Staff, Petra Galindez. LPA spoke with Administrator, Raushon Ahmed via telephone, while at the facility.

Today, LPA was at the facility regarding a complaint investigation and observed deficiencies. LPA observed a black box in the fridge storing a former resident's medication. The box was not locked and medications were made accessible to residents in care. The fridge/freezer located inside the facility did not have a sufficient food supply. The freezer contained frozen food items, such as Banquet dinners and pot pies. The freezer was not sanitary and had debris and particles. The fridge had 1 package of hot dogs and some tupperware that contained food, but it was unlabeled/unidentified. The pantry contained a bag of hot dog buns, a case of Top Ramen noodles and one case of canned vegetables. The fridge located in the garage contained an egg carton with 5 eggs, and one loaf of bread. The freezer had one zip lock bag with raw chicken, which was not labeled or dated. The freezer had dried blood all along the base of the inside of the freezer.

In addition, LPA requested resident records for Resident #1 (R1) and Resident #2 (R2) and was made aware by the administrator that the files were incomplete. The administrator stated the resident's were admitted to the facility without the required documentation due to the administrator being ill, and they were behind on their paperwork. LPA explained the importance on required documentation for admittance. Resident #3's Resident Appraisal was not current with a date of 08/2024. Also, R1 left the facility on 12/30/25 to go to the store and didn't return. The administrator did not complete an incident report and assumed the report was not needed, as R1 was not returning to the facility.

Deficiencies were observed and cited on the attached LIC 809D. A civil penalty is being assessed for a repeat violation within a 12 month period. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Petra Galindez whose signature below confirms receipt of these rights.

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Natasha Persaud
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2026
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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Document Has Been Signed on 01/05/2026 07:11 PM - It Cannot Be Edited


Created By: Natasha Persaud On 01/05/2026 at 11:50 AM
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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2026
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible...supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Administrator stated the medications belonged to a former a resident, the medications were removed and locked during the visit. The administrator agreed to attend training along with staff regarding medications being locked/inaccessible. The administrator will provide proof of
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Based on observations and interviews, the licensee did not ensure medications were centrally stored and made inaccessible to 2 out of 3 [R2-R3] residents, which poses an immediate health and safety risk to residents in care.
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scheduled training date by POC due date, tomorrow, and submit proof of training within 2 weeks.
Type B
02/02/2026
Section Cited
CCR87555(a)

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General Food Service Requirements. The total daily diet shall be of the quality and in the quantity...and shall meet the Recommended Dietary Allowances... Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Administrator explained they didn't have time to grocery shop. The administrator agreed to submit the grocery receipt to show sufficient food of good quality, along with a photo of purchased food items. In addition, both fridge/freezers will be cleaned to a healthful manner.
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This requirement is not met as evidenced by:
Based on observations and interviews, the licensee did not ensure the quality/quantity of food met the requirements for 3 out of 3 [R1-R3] residents, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Natasha Persaud
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/05/2026 07:11 PM - It Cannot Be Edited


Created By: Natasha Persaud On 01/05/2026 at 12:10 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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2026
Section Cited
CCR
87506(a)

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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:
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The administrator stated they will update the resident records and ensure they are maintained accurately by POC due date.
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Based on interviews and record review, the licensee did not maintain records for 3 out of 3 [R1-R3] residents and a former resident, which poses a potential health, safety and personal rights risk to residents in care.
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Civil Penalty issued for a repeat violation within a 12 month period.
Type B
02/02/2026
Section Cited
CCR87457(c)

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Pre-Admission Appraisal. Prior to admission...resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs...specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
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Administrator agreed to attend training on Pre-Admission Appraisals and provide proof of training by POC due date.
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Based on interviews and record review, the licensee did not complete a Pre-Admission Appraisal for 1 out of 3 [R2] residents and a former resident, which posed a potential health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Natasha Persaud
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/05/2026 07:11 PM - It Cannot Be Edited


Created By: Natasha Persaud On 01/05/2026 at 01:11 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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2026
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements. A written report shall be submitted to the licensing agency...in (A) through (D) below. This report shall...and disposition of the case. Any incident...such as psychological abuse of a resident by staff...or unexplained absence of any resident.
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Administrator stated the incident report was not completed due to R1 not returning. Administrator will ensure to submit incident reports on occurrences. Administrator agreed to submit an incident report for R1 by POC due date.
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This requirement is not met as evidenced by:
Based on interviews and record review, the licensee did not submit an incident report for 1 out of 3 residents [R1], which posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Natasha Persaud
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
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