365530247-2-5-2026-56-AS-BSIH-DQZT7H-20260205132847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530247
Report Date: 02/05/2026
Date Signed: 02/05/2026 01:30:19 PM

Document Has Been Signed on 02/05/2026 01:30 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CAPE MOUNT SPIRIT ARF		FACILITY NUMBER:	365530247
ADMINISTRATOR/ DIRECTOR:	KIJAN,SADIA;KIJAN,MICHAEL		FACILITY TYPE:	735
ADDRESS:	6547 SONOMA AVE		TELEPHONE:	(310) 498-9324
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY: 4		CENSUS: 0	DATE:	02/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Licensee/Administrator Sadia Kijan		TIME VISIT/ INSPECTION COMPLETED:	01:40 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	On 02/05/2026, Licensing Program Analyst (LPA) Beena Singh conducted an announced visit to the facility for a required annual visit.. LPA Singh met with Licensee/Administrator Sadia Kijan. The facility is an Adult Residential facility(ARF) with a license capacity of (4) and a current census (0). The facility has no clients in care and no staff working at the facility. The facility is waiting for clients from Inland Regional Center (IRC). LPA conducted an overall inspection, which included, but was not limited to, the following: Operational/Physical Structure: Facility is a two (2) story house with three (3) client bedrooms, one (1) staff bedroom and three (3) bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in front of the house. Central heating and air conditioning system installed with one (1) central panel located in the hallway to control entire house. Bedrooms: Each client bedrooms accommodate any ambulatory client. All client bedrooms were adequately furnished with bed, appropriate linens, adequate lighting, and an operable smoke/carbon monoxide alarm. However, LPA observed night stand in the rooms and dressers, night lights maintained in hallways going to clients shared bathrooms. LPA Singh verified water temperature was measured at 111 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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

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)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ARF	FACILITY NUMBER: 365530247
	VISIT DATE: 02/05/2026

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

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
will be secured in a locked closet located in the hallway. There was adequate room for food storage. LPA Singh observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in the garage reported to LPA not accessible to clients.
Living/Family room:
There was a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on right side of the house that leads
into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. LPA observed Community Care Licensing Division (CCLD) complaints poster, visitor policy, house rules, residents rights, Labor Laws observed posted in the common areas .
General items:
Two (2) fire extinguishers was charged and located in the pantry. Three (3) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet in the hallway. First Aid kit with required components, and locked area for medication storage was observed.
No records to review due to no clients in the facility and no staff working in the facility. Licensee/administrator has a current license for the facility.
No deficiencies were cited during today’s visit. An exit interview was conducted, and a copy of this report, LIC809, LIC809C, were discussed and provided to Licensee/Administrator Sadia Kijan.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3