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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530247
Report Date: 01/21/2025
Date Signed: 01/21/2025 10:20:35 AM

Document Has Been Signed on 01/21/2025 10:20 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CAPE MOUNT SPIRIT ARFFACILITY NUMBER:
365530247
ADMINISTRATOR/
DIRECTOR:		KIJAN,SADIA;KIJAN,MICHAELFACILITY TYPE:
735
ADDRESS:6547 SONOMA AVETELEPHONE:
(310) 498-9324
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 0DATE:
01/21/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Administrator-Sadia Kijan and Michael Kijan.TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 01/21/2025 at 9:40 AM, Licensing Program Analyst (LPA) Beena Singh conducted an announced second visit to the facility for purpose of Pre-licensing evaluation. LPA Singh met with Administrator/Applicant _Sadia Kijan and Michael Kijan.

An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 09/16/2020 for a total capacity of four (4) Ambulatory.

Pre-Licensing is complete with no deficiencies and has been resolved by 01/21/2025.

Licensee has Obtained night stand in the rooms and dressers, night lights for each client. Observed posters of CCLD Complaints poster, visitor policy, house rules, residents’ rights in the common areas. LPA Singh observed emergency food, water, and emergency supplies and EXIT sign on doors.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to
applicant/Administrator Sadia Kijan and Administrator Michael Kijan
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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