198320119-1-20-2026-11-AS-JCAN-DQDS56-20260116123348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320119
Report Date: 01/16/2026
Date Signed: 01/20/2026 09:56:38 AM

Document Has Been Signed on 01/20/2026 09:56 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	MONTOAK SENIOR LIVING INC.		FACILITY NUMBER:	198320119
ADMINISTRATOR/ DIRECTOR:	SHAHEEN, NAJMA		FACILITY TYPE:	740
ADDRESS:	1700 248TH STREET		TELEPHONE:	(310) 406-6193
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY: 12		CENSUS: 11	DATE:	01/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:18 AM
MET WITH:	ADMINISTRATOR NAJMA SHAHEEN		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	On 01/16/2026 at 08:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Montoak Senior Living Facility. LPA Calderon was allowed entry into the facility by Administrator Najma Shaheen. Facility is licensed to serve 12 non- ambulatory residents of which four (4) may be bedridden (room #1 and room #2 approved for bedridden) and approved for hospice waiver for six (6). None of the residents are diagnosed with dementia or receiving home health or hospice care services. Currently there are 11 residents in care. LPA Calderon explained to Administrator Najma Shaheen the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Six (6) client service records, six (6) client medication records, four (4) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 01/05/2026. The one-story residential home consists of eight (8) client bedrooms, four (4) client bathrooms, living room, dining room, kitchen, staff room, office area, garage with washer and dryer/ storage area. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage area.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Jose Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
	VISIT DATE: 01/16/2026

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Bathroom #3 hot water temperature is properly measured at 108 degrees Fahrenheit, Bathroom # 4, hot water temperature is properly measured at 108 degrees Fahrenheit, Kitchen hot water temperature is properly measured at 115 degrees Fahrenheit. Facility one (1) Carbon Monoxide and twelve (12) Smoke Detectors, hard-wired and connected, were tested and working properly. The facility two (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knives are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. A working landline phone was operational. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Six (6) client files were reviewed and found to be complete. LPA Calderon reviewed six (6) resident medications, and they were all found to be administered according to doctor's orders. Four (4) staff files were checked, and they have the required documents. LPA Calderon noted the Administrator Najma Shaheen Certification # 7013300740 expiration date of 04/12/2027 was valid at time of visit. The facility does NOT handle clients’ money/cash resources, and a NO Surety bond is needed. Commercial General Liability Policy #01002931911 policy period from 04/03/2025 to 04/03/2026 underwritten by Kinsale Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. All the required documents are posted in the facility in a clearly visible area.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Najma Shaheen.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Jose Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

LIC809 (FAS) - (06/04)

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