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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 12/11/2024
Date Signed: 12/11/2024 05:32:57 PM

Document Has Been Signed on 12/11/2024 05:32 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A & J RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331880906
ADMINISTRATOR/
DIRECTOR:		YOUNES, AMIRRAFACILITY TYPE:
735
ADDRESS:1229 KELLEY AVETELEPHONE:
(650) 656-7941
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 6DATE:
12/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:12 PM
MET WITH:Staff - Areil Galicia and Licensee Ahmed Oasim TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Mary Rico made an unannounced case management visit at the facility. LPA Rico met with staff Areil Galicia explained the reason for the visit. The Licensee Ahmed Qasim was contacted and informed regarding today's visit.

LPA Rico conducted a facility tour, audit clients P&I, audit clients records and conducted client interviews.

Based on the observations made during today’s visit,no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809 was discussed and provided to Licensee Ahmed Qasim.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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