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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604586
Report Date: 07/27/2022
Date Signed: 07/27/2022 05:19:48 PM

Document Has Been Signed on 07/27/2022 05:19 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:ELDERLY HAVENFACILITY NUMBER:
374604586
ADMINISTRATOR:AKHTER-RAHMAN, SYEEDA SELIFACILITY TYPE:
740
ADDRESS:10163 EMBASSY WAYTELEPHONE:
(858) 688-4667
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 5DATE:
07/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Applicant, Syeeda Selina Akhter-RahmanTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Prelicensing inspection. An initial application to operate a Residential Care Facility for the Elderly was received on 05/05/2022. The facility was approved to care for six (6) elderly residents; six (6) Non-Ambulatory, of which one (1) may be Bedridden. LPA was greeted and allowed entry into the facility by Staff, Merlina Aquino. LPA met with Applicant, Syeeda Selina Akhter-Rahman and Administrator, Mohammad Rahman.

Structure- The facility is a single story structure with 5 bedrooms and 2 bathrooms. There is an outdoor covered area for resident use. No bodies of water were observed.
Bedrooms Residents- Rooms #1-#5 may be used for Non-Ambulatory. Only one (1) bedridden at a time.
Bedrooms Staff- There is no staff bedroom.
Bathrooms- All bathrooms have a working toilet, sink, grab bars and tub/showers with non-skid mats.
Linens & Hygiene Supplies- Adequate supply.
Emergency Phone Numbers, Exit Plan and Required Postings- Posted.
Smoke Detectors and Carbon Monoxide Detectors- Interconnected and hardwired.
Appliances- Stove burners, oven, microwave, washer, and dryer working.
Toxins- Stored in a locked cabinet.
Water Temperature- Measured at 108 degrees F.
Medications- Centrally stored and locked in a cabinet
First-Aid Kit- Stored in a locked cabinet.
Resident & Staff Files- Located in a locked cabinet.
Activities- Adequate supplies. The facility has board games, and materials for the resident's use.
Fire clearance- Approved on 05/16/2022.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586
VISIT DATE: 07/27/2022
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Component III- Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance.

All items reviewed during the visit are in compliance. Prelicensing is complete and this facility has no deficiencies. Facility appears to be ready for licensure pending final review. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Applicant, Syeeda Selina Akhter-Rahmanwhose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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