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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701655
Report Date: 07/29/2026
Date Signed: 08/03/2026 03:37:45 PM

Document Has Been Signed on 08/03/2026 03:37 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALI SENIOR LIVINGFACILITY NUMBER:
342701655
ADMINISTRATOR/
DIRECTOR:		ALI, SAIMAFACILITY TYPE:
740
ADDRESS:5865 AMBLER STREETTELEPHONE:
(916) 337-5458
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 0DATE:
07/29/2026
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Saima Ali and Mobussar Ali TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 07/29/2026 at 11:00 AM, a meeting was conducted via Microsoft Teams. Those in attendance included Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Pang Lee, Licensee/Administrator Saima Ali, and Mobussar Ali, the Administrator's spouse. The purpose of the meeting was to discuss the facility's intent regarding a potential Change of Ownership (CHOW) and to provide guidance on the applicable licensing requirements.

The following topics were discussed during the meeting:

· The facility has had a census of zero since it was licensed.

· The Licensee advised that there was a potential buyer interested in purchasing the facility; however, the buyer ultimately decided not to proceed with the Change of Ownership.

· The Department explained the requirements regarding changes in a corporation or Limited Liability Company (LLC):

- A transfer of 50% or less ownership is generally not considered a change in ownership.

- A transfer of more than 50% (51% or greater) may constitute a change in ownership requiring a new application and licensure.

- The Centralized Applications Bureau (CAB) is responsible for reviewing and processing changes involving corporate ownership of 51% or more.

CONTINUED LIC 809-C

Arielle Pascua
Pang Lee
DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2026
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALI SENIOR LIVING
FACILITY NUMBER: 342701655
VISIT DATE: 07/29/2026
NARRATIVE
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· The Department discussed the Emergency Approval to Operate (EAO) process and explained that an EAO is reserved for emergency situations, such as the death of a licensee or a natural disaster, where immediate action is necessary to ensure continuity of care. Because the facility currently has no residents in care, there is no emergency that would warrant an EAO. Mobussar Ali asked whether the process could be expedited if residents were residing in the facility. The Department explained that the presence of residents alone does not constitute an emergency and would not qualify for expedited processing.

· The Department advised the Licensee that the facility may request to place the license on inactive status until a final decision is made regarding the future of the facility, such as pursuing a Change of Ownership, voluntarily closing the facility, or admitting residents. The Department explained that while the facility is on inactive status:

- No residents may be admitted.

- A timeframe for inactivity provided to CCLD.

- Annual licensing fees remain due but are assessed at a reduced rate.

- The facility may not be leased or used as a regular rental property.

The Licensee stated they would notify LPA Lee once a decision has been made.

· The Department also discussed the option of maintaining the facility's active license regardless of whether residents are admitted. The Licensee was informed that the Department retains its authority to conduct inspections and that annual licensing fees remain due even if the facility has no residents in care.

· If the facility is sold through a Change of Ownership (CHOW), the prospective owner must submit a LIC 200 Application for a Community Care Facility License and complete the licensing process before assuming responsibility for the facility. The Department further explained that if residents are in care during a CHOW, the current licensee remains legally responsible for the operation and care of the residents until the new license is issued. The Department also reviewed the requirement to provide at least 60 days' written notice to residents and their responsible parties, when applicable.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
LIC809 (FAS) - (06/04)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALI SENIOR LIVING
FACILITY NUMBER: 342701655
VISIT DATE: 07/29/2026
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· The Department advised the Licensee not to sign or execute any agreements related to the sale, transfer, or ownership of the facility without first consulting CCLD or notifying LPA Lee.

· The Department reminded the Licensee that resident records must be established and completed prior to admission. Required documents include, but are not limited to:

- Tuberculosis (TB) documentation;

- Health screening documentation;

- LIC 603, Pre-Admission Appraisal;

- LIC 603A, Resident Appraisal;

- LIC 601, Identification and Emergency Information; and

- LIC 625, Needs and Services Plan.

· The Department also explained that the Centralized Applications Bureau (CAB) is responsible for reviewing and processing:

- Initial license applications;

- Change of Ownership (CHOW) applications;

- Change of location applications;

- Changes to the legal entity (corporation, LLC, partnership, etc.)

Based on today's meeting, no deficiencies were cited. An exit interview was conducted with Saima Ali and Mobussar Ali. A copy of this report was provided via email, with a request that the signed copy be returned to LPA Lee no later than August 8, 2026.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
LIC809 (FAS) - (06/04)
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