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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603715
Report Date: 02/21/2026
Date Signed: 02/21/2026 02:37:53 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
01/16/2025 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20250116150125
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: 24DATE:
02/21/2026
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Med Tech Gloria CastroTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulting in serious bodily injury.
INVESTIGATION FINDINGS:
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13
On 02/21/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Medical Technician Gloria Castro and explained the purpose of the visit.

Regarding the allegation Neglect/Lack of Supervision resulting in serious bodily injury, during a visit a resident (R1) was found to have "severe swelling" to elbow and bruising on upper arm and was "experiencing severe pain when touched or moved".

During the investigation, staff members were interviewed, and records were reviewed.

(Cont. on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
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 5
Control Number 08-AS-20250116150125
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: 02/21/2026
NARRATIVE
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(Cont. from LIC 9099)

According to the interviews with facility staff, hospice care staff, and family member, R1 is bedridden and hardly moves while in bed. R1 has never attempted to climb out of bed without assistance and R1 has never been found on the floor after an unwitnessed fall. Hospice nurse, H3 stated he/she does not believe R1 suffered a fall.

There is no evidence or witnesses to corroborate the allegation of Neglect/Lack of Care and Supervision resulting in R1 sustaining a fractured left arm.

Based on interviews and records review, the department has determined that 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 allegations are UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Medical Technician Gloria Castro, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/16/2025 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20250116150125

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: 24DATE:
02/21/2026
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Medical Technician Gloria CastroTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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5
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10
11
12
13
On 02/21/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Medical Technician Gloria Castro and explained the purpose of the visit.

Regarding the allegation of Facility staff did not seek timely medical attention for resident, facility did not send resident (R1) for further medical treatment since R1 was expressing pain.

R1 first displayed pain on 1/12/2025. R1 complained of pain in R1s left wrist, however, staff did not see any swelling or bruising. S2 immediately notified hospice of pain and asked for a nurse to come to the facility to evaluate R1. A nurse did not visit R1, but S2 was instructed to give medication to mitigate R1s pain.

(Cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20250116150125
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: 02/21/2026
NARRATIVE
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(Cont. from LIC 9099)

On the evening of 1/13/2025, S2 heard R1 in the room screaming when a caregiver was attempting to change R1s clothing for bed. S2 went to check and noticed R1 had bruising from the left shoulder to the elbow and R1s elbow was swollen. S2 notified hospice of R1s condition. The hospice representative told S2 there was no on-call nurse available to visit R1 and that R1 had a scheduled visit with a hospice nurse on 1/14/2025. The nurse visited R1 on 1/14/2025 and had R1 transported to the hospital to be evaluated.

Hospice was notified immediately when R1 expressed pain in R1s left arm and again when bruising and swelling was noticed. Facility staff were directed by Hospice staff to give R1 the prescribed pain medication and did not send a nurse to the facility as requested to evaluate R1.

There was the delay as R1 had advised they were expressing pain. Although the facility did contact the hospice agency, the hospice agency advised they can’t come out until the next day and left R1 without medical care after expressing pain. It was not until the hospice agency came and then advised the facility to send R1 to the hospital. The facility should have sought further medical treatment since the resident was expressing pain.

At the time of the complaint visit the licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Medical Technician Gloria Castro, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250116150125
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2026
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed... (1)for medical and dental care appropriate to the conditions and needs of residents.

This was not met as evidenced by:
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Staff will provide proof of scheduled incidental medical care in-service training with all staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 02/24/2026.
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Based on interviews and records review, the facility did not meet the needs of R1 as there was a delay in sending R1 to get further medical treatment when R1 was expressing pain, which poses an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5