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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701451
Report Date: 11/24/2025
Date Signed: 11/24/2025 12:35:05 PM

Document Has Been Signed on 11/24/2025 12:35 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:KHANCAREFACILITY NUMBER:
502701451
ADMINISTRATOR/
DIRECTOR:		KHAN, AAMIRFACILITY TYPE:
735
ADDRESS:2625 LARAMIE DRTELEPHONE:
(209) 996-4663
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 4DATE:
11/24/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Aamir Khan TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/24/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a post licensing visit. LPA was greeted by Facility Designated Administrator (FDA), Aamir Khan and explained the purpose of the visit. The purpose of the visit is to conduct a post licensing visit.
Current census of this facility is 4. All residents were in their respective bedroom at the time of the visit.
This facility will hold 4 ambulatory residents. This facility also accepts and retains Level 6 residents from Valley Mountain Regional Center.
A brief interview with FDA Khan was conducted. There was one other staff member on site, Saqib Khan.
LPA Pascua reviewed 4 staff files. All staff files were missing the LIC501. LPA Pascua advised that facility must keep the LIC501 on file. All staff have completed Health Screening, TB testing, and have been background cleared. The Facility Designated Administrator also has an active administrator certificate #6069300735 and expires on 04/10/2026.
LPA Pascua reviewed 4 resident files.
A tour of the facility was initiated with FDA Khan.
This facility holds a medication cabinet located near the dining area. Along with FDA, LPA reviewed and compared medication logs to medication on site. This facility obtains monthly bubble packs through their contracted pharmacy.
One fire extinguisher was placed in the living room and was was purchased with a receipt attached on 11/24/2025.. Smoke detectors and carbon monoxide detectors were located throughout the facility and were observed to be functional and in compliance at this time.
All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KHANCARE
FACILITY NUMBER: 502701451
VISIT DATE: 11/24/2025
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Office rooms and other areas intended for resident use were toured.
Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible. An additional pantry was identified to store additional non-perishable food supplies.
Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of 4 resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time.
A review 2 resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. Grab bars were present and functional.

A tour of the laundry room was conducted. LPA observed toxins and laundry detergent locked and made inaccessible. A first aid kit was observed to be present and contained all the required components.

A tour of the garage was conducted. An additional refrigerator was located and will house additional perishable food supply. A locked storage unit was identified with cleaning supplies and toxins.

Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. This facility has two gate exits and were observed to be function.

Technical assistance was provided for Sections, 80069, 80020, 80070, and 80076.

Licensees were offered and agreed to an opportunity to participate in Department's Technical support Program.

Based on the observations made during today's visit, there are no deficiencies were observed or cited during this annual visit.

An exit interview was conducted and a copy of this report was given to Facility Designated Administrator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
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