<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604138
Report Date: 08/19/2025
Date Signed: 08/19/2025 12:38:04 PM

Substantiated


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
01/27/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250127114918
FACILITY NAME:PREMIUM CARE SERVICESFACILITY NUMBER:
374604138
ADMINISTRATOR:HAFIZ, SHEIKHFACILITY TYPE:
740
ADDRESS:8243 HYDRA LNTELEPHONE:
(858) 433-7319
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 5DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Sheik HafizTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not treat resident with dignity
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA was greeted and allowed entry into the facility by Staff, Roser Loja. The Administrator, Sheik Hafiz arrived during the visit.

During the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff did not treat resident with dignity. It was reported Staff #1 (S1) called Resident #1 (R1) bad names and goosed R1’s butt. It was explained S1 poked R1 between the buttocks. Outside source interviews revealed R1 used to goose people in their past and thought it was funny. S1 explained R1 would goose S1, so S1 admitted they did it back to R1, as a friendly gesture and they would both laugh. S1 denied calling R1 names. In addition, S1 was using rubber bands to tie the doorknobs together to hold the door shut. S1 was sleeping in the hallway outside of R1’s room and the light was disturbing S1 at night. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 5
Control Number 08-AS-20250127114918
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: PREMIUM CARE SERVICES
FACILITY NUMBER: 374604138
VISIT DATE: 08/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
S1 explained the rubber bands were used to hold the doors closed due to the light shining from R1’s room into the hallway. R1 was not treated with dignity when S1 goosed R1, by poking R1 in between their buttocks and using rubber bands to hold R1’s doorknobs closed. The licensee’s interview revealed they removed S1 from providing care to R1 and R1 is no longer sleeping in the hallway in front of R1’s room. S1 is currently residing in the garage. The administrator was made aware staff are not allowed to sleep in the garage unless approved by the Fire Department. The licensee stated they will submit documentation for the fire department review.

Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was 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 Administrator, Sheik Hafiz whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20250127114918
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: PREMIUM CARE SERVICES
FACILITY NUMBER: 374604138
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2025
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons.
1
2
3
4
5
6
7
The administrator stated staff are no longer sleeping in the hallway. The administrator agreed to have staff trained on personal rights and submit proof of training by POC due date.
8
9
10
11
12
13
14
Based on observations and interviews the licensee did not ensure 1 out of 5 [R1] residents were treated with dignity, which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
01/27/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250127114918

FACILITY NAME:PREMIUM CARE SERVICESFACILITY NUMBER:
374604138
ADMINISTRATOR:HAFIZ, SHEIKHFACILITY TYPE:
740
ADDRESS:8243 HYDRA LNTELEPHONE:
(858) 433-7319
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 5DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Sheik HafizTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff pushed resident, resulting in injury
Staff locked resident in the room
Staff did not ensure resident had access to incontinence equipment
Staff did not refill resident's medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA was greeted and allowed entry into the facility by Staff, Roser Loja. The Administrator, Sheik Hafiz arrived during the visit.

During the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged Staff #1 (S1) pushed Resident #1 (R1), resulting in R1 sustaining a scratch on the top of their hand. R1’s interview revealed they were pushed against their bedroom wall and sustained an unknown scratch. R1 was unable to determine how the scratch appeared. S1 denied pushing R1 against the wall and/or R1 sustaining an injury. S1 stated R1 was blocking the walkway and staff and residents could not pass through. Therefore, R1 was asked to move to the side, when R1 didn’t move, S1 guided R1’s arms holding onto their walker and guided them to the side so other residents could pass. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250127114918
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: PREMIUM CARE SERVICES
FACILITY NUMBER: 374604138
VISIT DATE: 08/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
S1 stated there was no scratch or injury that occurred. S1 stated, R1 scratched their hand on their walker. S1 offered to clean the skin tear, but R1 refused, it’s unknown how exactly R1 sustained the scratch. Outside source interview revealed the day the resident stated the incident occurred, there were no visible scratches or wounds. R1 also stated the same incident occurred at their prior facility. LPA observed the wall in the bedroom that R1 stated they were pushed against and noticed it was not possible as there was a bed located in the area reported. Resident interviews revealed they have never been pushed or injured by staff. Residents also reported not being aware of the incident. Staff interviews revealed they have not witnessed or heard S1 push R1 against the wall. Staff interviews stated R1 had a scratch on their hand, but they didn’t know how R1 sustained it.

It was also alleged that S1 locked R1 in their room by tying rubber bands around the doorknobs to lock R1 in their room. S1’s interview revealed they were sleeping on a cot in the hallway located outside of R1’s room. S1 stated they used large rubber bands around the two (2) doorknobs to hold the door closed due to the lighting coming through the door opening. The double doors to R1’s room do not close completely, allowing lighting through the opening of the double doors. S1 explained the door was not locked with the rubber bands, as the doors could easily be opened. R1’s interview confirmed their doors were never locked and they were able to enter and exit their room at any time. R1 was not aware of any rubber bands on their doorknobs.

It was also alleged that staff did not ensure R1 had access to incontinent equipment. It was reported that staff were hiding R1’s urinal at night. R1 is able to ambulate and use the restroom independently. R1 has a urinal for nighttime use to ensure safety from getting up to go to the bathroom at night. On 02/03/25, LPA observed two (2) urinals located in R1’s bedroom. R1 denied not having access to their urinal. Staff interviews confirmed R1 has two (2) urinals for nighttime use, as R1 uses the bathroom independently during the day. Staff explained that the urinals are only taken by staff to discard the urine and clean the urinals, then it’s returned to R1. R1 denied not having access to their incontinent equipment.

Lastly, it was alleged that staff did not refill R1’s medications. R1’s responsible party’s interview confirmed that they manage R1’s finances and the out of pocket cost for the medication was costly. Therefore, they didn’t always purchase it for R1. Also, due to R1’s medical insurance, some medications were held. R1’s responsible party explained the facility was not responsible for any errors with R1’s medications and R1’s primary care physician (PCP) was involved. R1’s responsible party also indicated R1’s physician’s assistant was calling in the refills to the pharmacy not the facility. In addition, R1 was no longer taking the medication in question, therefore, it was not refilled.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Sheik Hafiz whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5