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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001402
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:11:10 PM


Document Has Been Signed on 11/29/2022 02:11 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ALICIA CAREFACILITY NUMBER:
306001402
ADMINISTRATOR:SAEED, MUHAMMAD ANWARFACILITY TYPE:
740
ADDRESS:29742 ANA MARIATELEPHONE:
(949) 249-6610
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 2DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Muhammad SaeedTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Muhammad Saeed and explained the reason for the visit, his Administrator's Certificate expires on 12/28/2023. Facility has 6 bedrooms, 2 are for staff and 4 are for residents. 2 private resident rooms and 2 shared resident rooms, living room, dining room, kitchen and a 2 car garage. LPA and Administrator toured the facility. LPA observed the fireplace in the living room is closed off and inaccessible to residents. Administrator reported the fireplace cannot be used. LPA observed all resident rooms had the required furnishings and were clean and organized. Smoke detectors tested operational. Carbon monoxide detector tested operational. All fire extinguishers are fully charged. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. LPA observed the medication is kept locked in a kitchen cabinet. LPA observed hazardous items are kept locked under the kitchen sink. LPA observed all bathrooms were clean and operational. Hot water measured 108.3 degrees Fahrenheit. LPA and Administrator toured the backyard. There is shed in the backyard that is used for storage of old furniture. No bodies of water observed. The exit gate is operational. No obstacles or hazards observed in the backyard. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. LPA consulted with the Administrator concerning reporting requirements and continued Covid-19 mitigation requirements. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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