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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603715
Report Date: 12/09/2025
Date Signed: 12/09/2025 03:03:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 08-AS-20230428094732
FACILITY NAME:HARBORVIEW SENIOR ASSISTED LIVINGFACILITY NUMBER:
374603715
ADMINISTRATOR:SETTINERI, JEFFREYFACILITY TYPE:
740
ADDRESS:2360 ALBATROSS STREETTELEPHONE:
(619) 233-8382
CITY:SAN DIEGOSTATE: CAZIP CODE:
92101
CAPACITY:30CENSUS: DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Genoveva Guerrero TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident was sexually abused while in care
Resident sustained unexplained injury while in care.
INVESTIGATION FINDINGS:
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On 12/09/2025 at 3:00PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger meet virtually via Teams to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator Genoveva Guerrero.

During the course of investigation, the Department conducted interviews with staff, the resident and Witnesses.

On the allegation: Resident was sexually abused while in care.
interviews were conducted with R1, staff member S1, and witness W1. Although R1 has a diagnosis of dementia, she was alert, able to answer questions, and able to engage in conversation. S1 reported that R1 underwent colon surgery due to colon cancer, and the procedure was successful. R1 returned to the facility with a colostomy bag on 3/19/2023,
Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20230428094732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HARBORVIEW SENIOR ASSISTED LIVING
FACILITY NUMBER: 374603715
VISIT DATE: 12/09/2025
NARRATIVE
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...Continued from 9099
and staff from St. Paul’s PACE provided nursing support to monitor her condition. According to S1, R1 disliked the colostomy bag and would occasionally pull on the tubing, causing leaks and soiling her clothing and bedding. R1 was no longer able to use the toilet independently and began wearing adult diapers (Depends) to prevent accidents. Shortly after R1 began using Depends, staff observed a rash developing around her vaginal area. During the interview, R1 did not report any concerns regarding staff or her own well-being. Facility staff and PACE nursing staff continued to monitor her condition. Based on the information available, there is insufficient evidence to conclude that the blisters or rash in R1’s vaginal area were the result of sexual abuse.

On the allegation: Resident sustained unexplained injury while in care.
Interviews and documentation indicate that the blisters observed on R1 were identified by facility staff and promptly reported to the PACE nursing team and W2. Following recent surgery, R1 returned to the facility with a new colostomy bag. According to S1, R1 often expressed discomfort with the colostomy bag and would occasionally pull on the tubing, causing leaks that contributed to skin irritation and the development of blisters. Facility staff and PACE nursing staff monitored R1’s condition.
Based on the information obtained, there is insufficient evidence to conclude that R1’s injuries were the result of abuse or neglect. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2