<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006226
Report Date: 04/24/2024
Date Signed: 04/24/2024 03:24:03 PM

Document Has Been Signed on 04/24/2024 03:24 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:UMMA ADULT DAY HEALTH CENTERFACILITY NUMBER:
306006226
ADMINISTRATOR/
DIRECTOR:
CHAUDRY, SHAHIDFACILITY TYPE:
775
ADDRESS:14471 CHAMBERS RD #105TELEPHONE:
(949) 322-7811
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 65CENSUS: 0DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:59 PM
MET WITH:Shahid Chaudhry & Zain MateenTIME VISIT/
INSPECTION COMPLETED:
03:30 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
Licensing Program Analysts (LPAs) Michael Tea and Rose Ruppert with Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs and LPM were greeted and granted entry by Administrator Shahid Chaudhry and Assistant Administrator Zain Mateen Ahmad.

The facility is an Adult Day Health Center in a single story commercial building with an approved fire clearance of thirty ambulatory. The facility currently has no clients in care with two staff on duty. LPAs and LPM informed administrator to post the PUB 475 “See Something Say Something” poster at entryway prior to accepting clients.

During today’s visit, LPAs and LPM toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in one bathroom. The hot water temperature measured 108.6 degrees Fahrenheit and the smoke detector was operational. LPAs and LPM noted the bathroom toilet was in working order. The facility’s last fire drill was conducted on August 20, 2023.. Fire extinguishers were charged and serviced.

Facility had back-up emergency water supply located in employee kitchen. There are no cleaning supplies on-site.

LPA reviewed two of two staff training and fingerprint records. LPA interviewed staff regarding activities intended to be provided, program plan, outings and transportation.

Continued...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: UMMA ADULT DAY HEALTH CENTER
FACILITY NUMBER: 306006226
VISIT DATE: 04/24/2024
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
26
27
28
29
30
31
32
Facility has no clients in care. Prior to accepting clients licensee shall notify licensing agency of intent to accept clients.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Shahid Chaudhary and Zain Mateen Ahmad and a copy of the report was given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3