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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320604
Report Date: 09/11/2026
Date Signed: 09/11/2026 02:35:35 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/11/2026 02:35 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PACIFIC CARE ASSISTED LIVINGFACILITY NUMBER:
198320604
ADMINISTRATOR/
DIRECTOR:		KHAN, ANWER MOHAMMEDFACILITY TYPE:
740
ADDRESS:406 W 234TH STTELEPHONE:
(310) 920-4696
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 2DATE:
09/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Anwer Khan (Adminstrator)TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 09/10/2026 at 09:05am, Licensing Program Analyst (LPA)Zina Brown arrived at the the facility to conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one year annual inspection. At 9:40am,the Department met with Anwer Khan (Administrator) and the purpose of the visit was discussed. Please be advised due to technical difficulties, the Department was unable to generate electronic inspection tool and instead used a printable PDF version.

Facility is licensed to serve 6 non-ambulatory residents of which 1 maybe bedridden in bedroom #4 and a waiver granted for hospice care for 4 residents. None of the residents are diagnosed with dementia nor have any restricted health conditions and are not receiving home health, hospice care and palliative services. The facility does not handle any of the residents’ money.

The facility holds a administrator certification #7031623740 for Anwer Khan which is valid from 09/25/2025 - 09/24/2027. The facility has liability insurance with James River (policy #00166956-0) effective date 10/23/2025 - 10/23/2026 with each occurrence $1,000,000 and general aggregate at $3,000,000. The facility fee were paid in full on 09/11/2026 (approval #09526G) during the time of this inspection.

The home is a single story home with four (4) bedroom, two (2) bathroom, a garage, a living room, dining room, kitchen, laundry room and an backyard with a garden and an outdoor shaded area.

Janae Hammond
Zina Brown
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
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.

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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PACIFIC CARE ASSISTED LIVING
FACILITY NUMBER: 198320604
VISIT DATE: 09/11/2026
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LPA toured the Anwer Khan (Administrator) tour the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 105 °F - 120 °F (108.5 °F. in kitchen, 105.1 °F. in bathroom 1 & 111.5 °F in bathroom 2. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

The Department conducted a records review of (2)resident records, (2)staff records, (0) resident Personal & Incidental Records, and (2) Resident Medication Administration Records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); The observed the following deficiencies:
Staff 1 (S1) no LIC 503 with TB Test Results.
Staff 2 (S2) not associated to the facility in Guardian during the inspection.
Resident 1 (R1) no LIC 503 with TB Test Results.
Resident 1 (R1) & Resident 2 (2) no physician order for the use of postural supports such as bedrails.

Exit interview conducted with Anwer Khan (Administrator) and copy of this report was provided with appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 02:35 PM - It Cannot Be Edited


Created By: Zina Brown On 09/11/2026 at 01:38 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PACIFIC CARE ASSISTED LIVING
FACILITY NUMBER: 198320604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2026
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2)Obtain a California clearance or a criminal record exemption as required by the Department
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The facility shall associate S2 Johana Sigarlaki in Guardian and submit proof of update via email at zina.brown@dss.ca.gov by POC due date.
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Based on observation and interview S2 Johana Sigarlaki were not associated to the facility as the time of unannounced annual inspection which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 02:35 PM - It Cannot Be Edited


Created By: Zina Brown On 09/11/2026 at 01:47 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PACIFIC CARE ASSISTED LIVING
FACILITY NUMBER: 198320604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
CCR
87412(a)(11)

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(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11)A health screening as specified in Section 87411, Personnel Requirements - General.
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The facility will submit proof of LIC 503 with TB Test result for S1 Anwer Khan via email at zina.brown@dss.ca.gov by POC due date.
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Based on observation and interview: S1 Anwer Khan did not have proof of LIC 503 Health Screening with TB Test Results which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
10/02/2026
Section Cited
CCR87506(a)

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(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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The facility will submit proof of LIC 602 with TB Test result for R1 Ruby Turner via email at zina.brown@dss.ca.gov by POC due date.
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Based on observation and interview: R1 Ruby Turner did not have proof of LIC 602 Health Screening with TB Test Results which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 02:35 PM - It Cannot Be Edited


Created By: Zina Brown On 09/11/2026 at 02:08 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PACIFIC CARE ASSISTED LIVING
FACILITY NUMBER: 198320604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
CCR
87608(a)(3)

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(a) Based on the individual's preadmission appraisal. . . Postural supports may be used under the following conditions (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. Based on observation, interview and records review: R1 Ruby
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The facility will submit proof of physician order indicating the need for postural support for bedrails for R1 Ruby Turner & R2 Joseph Cook via email at zina.brown@dss.ca.gov by POC due date.
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Turner with full bed rails & R2 Joseph Cook with half bedrails & the Dept did not observe proof of physician order indicating the need for postural support which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


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