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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005707
Report Date: 06/07/2022
Date Signed: 06/08/2022 09:34:38 AM

Document Has Been Signed on 06/08/2022 09:34 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:KHAN GUEST HOMEFACILITY NUMBER:
397005707
ADMINISTRATOR:KHAN, HANIFFACILITY TYPE:
735
ADDRESS:12773 N LOWER SACRAMENTO ROADTELEPHONE:
(209) 329-5689
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 6CENSUS: 6DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mohammed Lughmani, Direct Support StaffTIME COMPLETED:
12:30 PM
NARRATIVE
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On 06/07/2022 at 10:00 AM, LPA T. White arrived unannounced to conduct a Required 1-year Annual inspection. LPA met with Direct Support Staff, Mohammed Lughmani and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 75 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 116.8 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishable and 2-day perishables foods.

LPA observed smoke detectors interconnected with the fire department. Carbon monoxide in operating condition during inspection. Fire extinguisher was last serviced on May 01, 2022. First aid kit was observed to be complete. Emergency Disaster Plan last posted 02/13/20222. LPA reviewed 4 client files and 3 staff record files.

- LPA observed clogged sink in the clients shared bathroom.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Direct Support Staff. Appeal rights and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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Document Has Been Signed on 06/08/2022 09:34 AM - It Cannot Be Edited


Created By: Treana White On 06/07/2022 at 11:58 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: KHAN GUEST HOME
FACILITY NUMBER: 397005707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 80087(a). LPA observed clogged sink in clients shared bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Facility staff agreed to repair sink and submit proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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