Pre-licensing visit·August 8, 2025

Licensing Program Analyst (LPA) Jose Tan conducted an announced Pre-Licensing Inspection with the applicant representative and Administrator Nirvana Mahmoodzaoeh and Noraet Neshayn. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 01/09/25 A fire clearance was approved on 05/29/25 for six (6) non-ambulatory residents on Room 2,3 & 4 only, one (1) of which maybe bedridden on Room #3 only. Two (2) bedrooms (Room #1 & 5) are for ambulatory resident only. The applicant will also be requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual and inter-connected. The facility has a brand-new fire extinguishers located by the dining area and hallway and last purchased on 08/08/25. At 9:27 AM, with the assistance of the administrator and applicant representative, a tour of the physical plant was in and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, stove/oven, microwave oven and sink. There was an adequate supply of non-perishable food items observed. Perishable food items not required at this time as there are no residents. Administrator was advised facility needs to carry perishable food items once they admit residents for care. Knives were observed locked in a kitchen cabinet. Cleaning supplies observed locked underneath the kitchen sink. BEDROOMS: There are three (3) bedrooms designated for client use. All three (3 bedrooms will be shared. The bedrooms were observed to have appropriate furniture and sufficient lighting. (continued on LIC 809-C) (continued from LIC 809) BATHROOMS: The facility has four (4) bathrooms. Bedroom #1 has its own bathroom with shower and designated for staff use only. The other two (2) bathrooms is located in the common area, by the kitchen bedrooms and by the dining area. One (1) other bathroom is in Room #5. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at a range of 114.6°F to 115.9°F COMMON AREAS: These included the living room and dining room areas. The living room has a couch, chair, table, and television. There is a shaded area with furniture in the backyard for residents' use. The dining room has a table large enough to seat six (6) residents. LAUNDRY ROOM: The laundry area is located in the backyard. It was observed to be locked during visit. GARAGE is attached to the house but has no access from the inside, it is also being used as emergency food, PPE, tools, frozen food and other miscellaneous storage. MEDICATIONS: Medications will be kept locked in the bedroom hallway cabinet. Complete First aid kit is located by the medication cabinet. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility is large enough to hold outdoor activities. There is a tool shed at the back but was observed to be locked during visit. There is no body of water in the facility. Component III orientation was waived with the approval of LPM Troy Agard as the would be administrator Nirvana Mahmoodzaoeh Ghaemi has more than three (3) years experience as an Administrator. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready to be licensed. CAB will be advised and a copy of this report provided Exit interview conducted. Copy of this report issued.