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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604264
Report Date: 11/06/2025
Date Signed: 11/06/2025 05:23:33 PM

Document Has Been Signed on 11/06/2025 05:23 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:NIR COMMUNITY IIIFACILITY NUMBER:
374604264
ADMINISTRATOR/
DIRECTOR:		HUQ, RANAFACILITY TYPE:
740
ADDRESS:10975 JANICE CTTELEPHONE:
(858) 414-5095
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 4DATE:
11/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Staff, Milagros GalvanTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Deficiencies visit. LPA identified herself and was allowed entry into the facility by Staff, Conchita Gallardo. LPA discussed the purpose of the visit with staff present. Administrator, Faria Huq and Licensee, Rana Huq arrived during the visit.

During a complaint investigation, it was discovered the licensee did not submit an incident report involving Resident #1 (R1). On 10/29/25, R1 wandered away from the facility and staff were not aware. R1's Physician's Report dated 05/08/2023 indicated R1 was ambulatory, and had a diagnosis of a Major Neurocognitive disorder. It also indicated R1 was unable to leave the facility unassisted. The licensee failed to report the incident.

Today, LPA observed the following deficiencies: A padlock on the front door and a locking device on R1's sliding door exit located in their room. Staff explained R1 wanders, therefore, the locks were put in place to prevent R1 from wandering from the facility; Cough syrup was on the kitchen counter, accessible to residents; A new laundry room was built but the lock was inoperable and could not be locked, which made cleaning supplies and items that pose a danger accessible; Sharp tools were observed in the backyard; The resident's files did not contain Absentee Notifications; and medical assessments were not within a year for R1 and Resident #2, as the reports were issued in 2023.

In addition, the licensee made alterations to the facility. Licensee stated licensing was not notified of the alterations to the facility because a permit was not required by the City to add a wall, which was added for the new laundry room. Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Natasha Persaud
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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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Document Has Been Signed on 11/06/2025 05:23 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/06/2025 at 02:39 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: NIR COMMUNITY III
FACILITY NUMBER: 374604264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
CCR
87202(a)

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Fire Clearance. All facilities shall maintain a fire clearance approved by the city...or the State Fire Marshal. Prior to accepting or retaining...obtain an appropriate fire clearance...or the State Fire Marshal. This requirement is not met as evidenced by:
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Administrator removed all locks during the visit. Administrator stated they will provide training regarding supervision and danger in locking residents inside the facility and provide proof of training by POC due date.
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Based on observations and interviews, the licensee did not comply with their fire clearance, by using a padlock to lock the front door, enabling residents to exit for 4 out of 4 [R1-R4] residents, which posed an immediate health, safety and personal rights risk to residents in care.
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An immediate $500 civil penalty was assessed for fire clearance violation.
Type A
11/07/2025
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored:
Centrally stored medicines shall be kept in a safe and locked place that is not accessible... supervision of the centrally stored medication.
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Administrator stated they will schedule training on centrally storing medication and provide scheduled training dates by POC due date. In addition, the training will be submitted within 2 weeks.
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This requirement is not met as evidenced by: Based on observations, the licensee did not centrally store medications making them accessible to 1 out of 4 [R1] residents, which posed an immediate 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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 05:23 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/06/2025 at 03:07 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: NIR COMMUNITY III
FACILITY NUMBER: 374604264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
CCR
87309(a)

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Storage Space and Access. Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...tools, sharp objects...are in locked storage and are not left unattended if outside the locked storage.
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Administrator locked the tools and replaced the lock on the laundry room, making them inaccessible to residents. Proof of scheduled training for ensuring items are properly stored by POC due date. In addition, proof of training will be submitted within 2 weeks.
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This requirement is not met as evidenced by:
Based on observations, the licensee did not ensure cleaning supplies and tools were inaccessible to 4 out of 4 [R1-R4] residents, which poses an immediate health and safety risk to residents in care.
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Type B
12/04/2025
Section Cited
CCR87211(a)(1)

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Reporting Requirements. A written report shall be submitted to the licensing agency...of any of the events specified in (A) through (D) below. This report shall include...date and nature of event...findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
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Administrator stated she will attend training on reporting requirements and submit an incident report for R1 by POC due date.
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Based on interviews and record review, the licensee did not report an incident for 1 out of 4 [R1] residents, 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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 05:23 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/06/2025 at 03:50 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: NIR COMMUNITY III
FACILITY NUMBER: 374604264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2025
Section Cited
CCR
87463(h)

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Reappraisals. The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by:
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Administrator stated R1 and R2 will be evaluated by a medical professional and documentation will be submitted by POC due date.
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Based on interviews and record review, the licensee did not obtain an annual routine medical visit for 2 out of 4 [R1-R2] residents in care, which posed a potential health and safety risk to residents in care.
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Type B
12/04/2025
Section Cited
HSC1569.317

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Absentee notification plan for missing residents. Every residential care facility...resident is missing from the facility...plan shall include...
administrator...inform authorized representative...notify local law enforcement...is missing from the facility.
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Administrator stated they will submit an Absentee Notification Plan for residents for 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 ensure 4 out of 4 [R1-R4] residents had an absentee notification in their written record of care, 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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NIR COMMUNITY III
FACILITY NUMBER: 374604264
VISIT DATE: 11/06/2025
NARRATIVE
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While at the facility, the licensee emailed LPA proof of permit for the Additional Dwelling Unit (ADU), along with an updated LIC 999 Facility Sketch to identify the new additions. The administrator explained the ADU has renters that have no access to the facility or residents.

During the visit, R1 attempted to exit the facility unassisted through their sliding door located in their room. Staff was able to immediately redirect R1. Licensee and administrator were made aware of the exit seeking behavior. They were also notified awake staff was required for wandering residents. They ensured R1's needs will be met.

Deficiencies were observed and cited along with a civil penalty for a fire clearance violation. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Milagros Galvan 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: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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