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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320191
Report Date: 08/11/2026
Date Signed: 08/12/2026 08:07:52 AM

Document Has Been Signed on 08/12/2026 08:07 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:FORT FAITH RCFEFACILITY NUMBER:
198320191
ADMINISTRATOR/
DIRECTOR:		FORT, NISHAFACILITY TYPE:
740
ADDRESS:710 LACONIA PLTELEPHONE:
(213) 362-8837
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 4CENSUS: 2DATE:
08/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:06 AM
MET WITH:Nisha Fort (Administrator)TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On 08/11/2026 at 08:06am, Licensing Program Analyst (LPA) Zina Brown arrived at the facility to conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the 1 year inspection. LPA met with Nisha Fort (Administrator) and the purpose of the visit was discussed. Facility is licensed age 60 and over and is approved for 4 ambulatory. None of the residents are diagnosed with dementia nor receiving home health, hospice care or palliative care services. The facility does not handle any of the residents’ money.

The facility has liability insurance with Primary Care Insurance, a Risk Retention Group, Inc (NAIC #16959) ; policy # PCI71568676-02 which is valid from 05/17/2026 - 05/17/2027. The facility has a surety bond (Bond #496441D) with a bond amount of $3000 effective as of 08/11/2026 - 08/11/2027 ; Agent: Brooklyn Ventures Suretybonds.com Insurance Agency LLC. The annual fee are a balance of $0 ; paid in full. The facility holds a Administrator Certification for Nisha Fort #7032985740 which is valid from 12/02/2025 - 12/01/2027.

The home is a single story home consisting of: (3) bedrooms of which 1 is currently vacant, (2) bathrooms, living room, kitchen with dining area, laundry area inside the kitchen with a washer and dryer and an outdoor shaded patio area.

At 8:20am, the Department toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 118.8 in kitchen & 117.6F in bathroom Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Between the hours of 8:40am - 9:40am, the Department conducted a records review of (2) client records, (2) staff records, & (2) Medication Administration Record. The last evacuation drill was conducted on 07/10/2026. The department reviewed the facility disaster plan which is current and in compliance with Title 22 at the time of visit. LPA observed the following not in compliance:

Janae Hammond
Zina Brown
DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2026
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: FORT FAITH RCFE
FACILITY NUMBER: 198320191
VISIT DATE: 08/11/2026
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Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8)
The department observed the following deficiencies:
87506(a) Resident Record
(2) Personal & Incidental (P & I) Records for R1 & R2

80066(c) Personnel Records
(2) First Aid/CPR for A1 and S1
(1) 20 Hours of Staff Training for S1
(2) LIC 501 Personnel Record for A1 & S1

Exit interview conducted with Nisha Fort (Administrator) and a copy of this report was provided with appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2026 08:07 AM - It Cannot Be Edited


Created By: Zina Brown On 08/11/2026 at 10:03 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: FORT FAITH RCFE
FACILITY NUMBER: 198320191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review) the licensee did not comply with the section cited above 2 out of 2 residents Personal & Incidental (P & I) Records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2026
Plan of Correction
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The facility will submit proof of Personal & Incidental (P & I) Records for R1 & R2 by POC due date to Department via email at Zina.Brown@dss.ca.gov
Type B
Section Cited
CCR
87412(g)
87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above 2 out of 2 staff LIC 501 for A1 & S1, LIC 501 Personnel Record for A1 & S1 & 20 hours of staff training for S1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2026
Plan of Correction
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The facility will submit LIC 501 for A1 & S1, First AId/CPR for A1 & S1, and Staff Training for S1 by POC due date to the Department via email at Zina.Brown@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2026


LIC809 (FAS) - (06/04)
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