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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700611
Report Date: 04/26/2024
Date Signed: 04/26/2024 12:56:28 PM


Document Has Been Signed on 04/26/2024 12:56 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:QURESHI CARE HOMEFACILITY NUMBER:
392700611
ADMINISTRATOR:UMER QURESHI, MUHAMMADFACILITY TYPE:
735
ADDRESS:9555 PRISCILLA LANETELEPHONE:
(209) 565-5258
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:5CENSUS: 5DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Umer Qureshi, Tania Frias, Ali QureshiTIME COMPLETED:
01:10 PM
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On 04/26/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Umer Qureshi, Tania Frias, Ali Qureshi and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for five ambulatory clients. There are currently five clients who reside at this facility.

The LPA Martinez toured the facility with the Ali qureshi on 04/26/2024 at 1:00 PM.

LPA Martinez reviewed three client files and three staff files, and all files were maintained. LPA Martinez reviewed three medication administration records (MAR), and the MARs were complete. The last fire drill was on April 1, 2024. The fire extinguisher, carbon detectors, and smoke detectors are in good repair. The exterior emergency exit door is in good repair. The facility has liability insurance and surety bond. The facility common areas, client bedrooms, bathrooms, laundry room were sanitary and in good repair. The facility has an adequate food supply. The facility has an area for activities, and has a public telephone. The facility has a infection control plan and has a natural disaster plan.

Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code. There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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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