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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701569
Report Date: 03/24/2025
Date Signed: 03/25/2025 09:52:47 AM

Document Has Been Signed on 03/25/2025 09:52 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:A&N CARE HOMEFACILITY NUMBER:
392701569
ADMINISTRATOR/
DIRECTOR:		KHATTAK, NAUMANFACILITY TYPE:
735
ADDRESS:207 ROGAN WAYTELEPHONE:
(209) 452-7002
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 4CENSUS: 0DATE:
03/24/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nauman KhattakTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 03/24/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Applicant, Nauman Khattak, who was interviewed at this time.
It was learned that this applicant is also seeking vendorization through Valley Mountain Regional Center (VMRC) to be able to accept and retain up to (4) Level 6 residents at any given time.
Current census was 0 residents.
A tour of the facility kitchen area was conducted. Kitchen drawers and cabinets were reviewed. It was observed that there was a sufficient supply of plates, cups, and other dinnerware/flatware made available to meet the needs of the residents at this time.
Knives and other sharp objects were observed to be stored in a manner that was locked and made inaccessible to the residents at this time.
A review of the facility 2-day perishable and 7-day nonperishable food quantities was conducted and observed to be sufficient and able to meet the needs of the residents at this time.
Pantry closet was toured. First aid kit was observed to be stored in this location at this time. All required components for the first aid were observed to be present and in compliance at this time.
Sample copies of the facility resident files were observed to be present at this time.
Sample copies of the facility staff files were observed to be present at this time.
A review of the facility Medication Administration Record was conducted at this time.
A tour of the dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Fire extinguishers, located throughout this facility on both floors, were observed to have been annually purchased from the local hardware company, Home Depot, on 01/13/2025 and in compliance at this time.
A tour of the resident bedrooms (4) was conducted on the second floor. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms (2) was conducted on both the first and second floor. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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 2
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: A&N CARE HOME
FACILITY NUMBER: 392701569
VISIT DATE: 03/24/2025
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degrees at all times.
Garage area was toured. Drawers and cabinets were observed to be present and in functional order at this time.
Additional food storage units were observed to be present in this garage area and in functional order at this time.
Detergents, cleaning agents, and supplies were observed to be locked and made inaccessible to the residents at this time.
Laundry room was toured on the second level. It was observed that cabinets housing laundry supplies were locked and made inaccessible to the residents at this time.
A tour of the facility exterior grounds was conducted. The facility perimeter fence, side gates, and all other exits were reviewed and observed to be in compliance at this time.
All required postings for Department of Labor (DOL), Workers' Compensation, and CDSS complaint hotline were observed to be present and in compliance at this time.
Administrator certificate for applicant, Nauman Khattak, was observed to have been completed with an expiration date of 01/09/2027 with number #6073753735.

Component III interview was conducted with the present Applicant at this time.

This facility was found to be in compliance at this time.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
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