365530326-8-6-2025-56-AS-RHSL-DKAPXV-20250806114255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530326
Report Date: 08/06/2025
Date Signed: 08/06/2025 11:43:15 AM

Document Has Been Signed on 08/06/2025 11:43 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:	FISHER MANOR 1		FACILITY NUMBER:	365530326
ADMINISTRATOR/ DIRECTOR:	QASIM, AHMED		FACILITY TYPE:	740
ADDRESS:	25243 FISHER ST		TELEPHONE:	(650) 452-2554
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92404
CAPACITY: 15		CENSUS: 8	DATE:	08/06/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:31 AM
MET WITH:	Administrator, Ahmed Qasim		TIME VISIT/ INSPECTION COMPLETED:	11:50 AM

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 08/06/2025 at 9:30AM Licensing Program Analysts (LPAs) Renese Howell-Small and Edith Conchas conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. I met with Administrator/Licensee, Ahmed Qasim. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 12/01/2024 for a total capacity of fifteen (15) residents, 10 ambulatory and (5) non-ambulatory. Fire clearance was granted on 02/04/2025. LPAs observed the following: Structure: Facility is a house with (8) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen and backyard. Heating /Cooling System: Central heating and air conditioning system installed with three control panels located in the hallway. Bedrooms: All bedrooms are adequately furnished with bed, chair, closet, appropriate linens, adequate lighting and licensee/administrator will install night lights in the hallway. Bathrooms: All bathrooms have working toilets, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. The water temperature was measured at 116 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

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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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FISHER MANOR 1	FACILITY NUMBER: 365530326
	VISIT DATE: 08/06/2025

NARRATIVE

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Kitchen:
The kitchen has an adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen drawer next to sink. There was adequate room for food storage. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition.

Kitchen:
There was sufficient storage for perishable food. There was adequate seating for meals for all clients.

Laundry:
Laundry room with washer and dryer was located near the main hallway. Laundry detergents, cleaning supplies and personal care items are kept locked in the laundry room.

Living /Family Room:
There was a living/family room with a TV and adequate seating for all clients.

Linens and Hygiene:
An adequate supply of linens was stored in a cabinet in the living room area.

Yards/Outdoors:
There is sufficient covered seating area in the backyard. There is a gate on the left and right side of the facility. The gate on the left side is the exit and is self-latching. All outdoor pathways were free of obstructions.

Emergency Phone Numbers and Exit Plan:
Facility sketches were observed posted in the kitchen area . There were four (4) fire extinguishers, carbon monoxide detectors and smoke detectors which are working and in good condition.

General items:
Client records will be stored in a locked cabinet in the office area. First Aid kit with required components are located in the medications cabinet. Medication will be locked in a cabinet in the office area. LPAs observed a facility phone and it was verified to be operational. Emergency water supply was observed. Administrator will complete a emergency food/supplies container.

An exit interview was conducted, no deficiencies were cited, Component III was completed during this visit and a copy of this report was reviewed and provided to Administrator Ahmed Qasim. .

According to Title 22 California Code of Regulations, Licensee/Administrator Ahmed Qasim has satisfied all of these requirements and is ready for licensure.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC809 (FAS) - (06/04)

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