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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530227
Report Date: 09/04/2026
Date Signed: 09/04/2026 10:15:25 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/04/2026 10:15 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JORDAN SENIOR HOMEFACILITY NUMBER:
365530227
ADMINISTRATOR/
DIRECTOR:		HUSSEIN, SHADENFACILITY TYPE:
740
ADDRESS:7051 GABELS CREST PLACETELEPHONE:
(205) 777-9144
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 6DATE:
09/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Licensee/Administrator Shaden HusseinTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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On 09/04/2026, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required Annual/comprehensive inspection. LPA Singh met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and Six(6) residents present. Licensee/Administrator Shaden Hussein arrived during the visit. LPA Singh explained the purpose of the visit to Licensee/Administrator Shaden Hussein.

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) are ambulatory residents. The facility has two (2) Hospice waiver and Assisted living waiver (ALW). The current census is six (6) residents. LPA Singh was accompanied by Licensee/Administrator Shaden Hussein to conduct a general overall inspection, which included, but was not limited to, the following:


Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA observed no obstructions to indoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, and storage space, lamps and chairs and sufficient lighting in the bedrooms.

Moreover, LPA observed that bathrooms were clean, and appliances were operating appropriately. LPA observed grab bars and non-skid mat in the resident bathrooms

Efren Malagon
Beena Singh
DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2026
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.

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JORDAN SENIOR HOME
FACILITY NUMBER: 365530227
VISIT DATE: 09/04/2026
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LPA observed night light maintained in hallways and passages to non-private bathrooms. LPA observed the outdoor passageways free of obstructions. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the resident bathroom to be at 119 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the Community Care Licensing Division(CCLD) complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. Cleaning supplies and sharps were kept inaccessible to residents in care

There was a designated storage space near dining area, for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Emergency food and water supply was stored

Care & Supervision: LPA observed sufficient number of staff to provide care and supervision to the residents in care and staff scheduled to work at night as required for facility with dementia residents.

Completed Emergency Kit and first aid manual observed at the facility.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. LPA also reviewed Administrator's file for certification and training. Records review was completed, no issues.

Facility emergency/ disaster/fire drill conducted on 08/07/2026. Liability Insurance valid through 12/19/2025-12/19/2026. LPA Singh reviewed medications administration records(MAR), no issues.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the of the California Code of Regulations.



An exit interview was conducted where this report, LIC809, LIC809C were discussed and provided to Licensee/Administrator Shaden Hussein.
NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026
LIC809 (FAS) - (06/04)
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