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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604273
Report Date: 10/29/2025
Date Signed: 10/29/2025 02:25:56 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
10/15/2025 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20251015152339
FACILITY NAME:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR:FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver Nelia EbuenTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation and to deliver the finding regarding the above-mentioned allegation. LPA was greeted by Caregiver Nelia Ebuen, identified herself, and discussed the purpose of their visit.. LPA was later joined by Caregiver Myrna Arcelao.

The Department’s investigation included staff and outside source interviews, and reviews of resident, staff, and outside source records.

On October 15, 2025, Community Care Licensing (CCL) received a complaint that alleged staff (S1) handled a resident (R1) in a rough manner. A review of R1’s records revealed they were admitted to the facility in August of 2018, with a diagnosis of Dementia. Additional review of R1’s records dated January 9, 2021, also revealed R1 was non-ambulatory, confused, and had a history of wandering behavior. During LPA’s initial visit she visited R1 in their facility room. LPA observed R1 to be disoriented to place and time and was unable to stand up without assistance.

[Continued on LIC 9099C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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 3
Control Number 08-AS-20251015152339
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: CASA MAHAL
FACILITY NUMBER: 374604273
VISIT DATE: 10/29/2025
NARRATIVE
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An interview conducted with an outside source (OS1) revealed upon the transport driver's (OS2) arrival at R1's appointment they refused to exit the transport van. OS1 disclosed that OS2 revealed they returned R1 to the facility and upon arrival OS2 went to the front door for assistance getting R1 out of the van and two staff members (S1 and S2) came out to assist. S1 entered the van, while S2 stayed outside the van with OS2, and S1 was observed to be rough and abrasive when they assisted R1 out of the transport van. OS2 also disclosed that the other staff member (S2) did not intervene. An interview conducted with OS2 corroborated OS1’s statement and disclosed upon arrival to R1’s appointment contacted the transport agency's dispatch line to notify them they would be returning R1 to the facility because R1 would not get out of the van.

The interview with OS2 also corroborated they observed S1 was rough with R1 and stated S1 grabbed R1 by the arm and forced them out of the van, and they rushed R1 by making comments such as “hurry up” “come on”. The Department also received footage of the incident that corroborated the chain of events described above, and from a different point or view (from the footage) S1 is also seen grabbing R1 by the seat of their pants. A review of the facility staff schedule confirmed S1 was the staff in question. [See LIC 811 for confidential names]

Based on interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D).



An exit interview was conducted with Caregiver Arcelao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) will be provided at the conclusion of the visit. Caregiver Arcelao's signature below confirms receipt of these documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20251015152339
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: CASA MAHAL
FACILITY NUMBER: 374604273
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2025
Section Cited
CCR
87468.1(a)
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Residents in all residential care facilities for the elderly shall have all the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.

This regulation was not met as evidenced by:
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Caregiver Arcelao recommended and agreed to have staff attend a CCL approved vendorized training conducted on personal rights for residents in care.

Caregiver Arcelao will provide proof of completion by POC due date.
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Based on interviews and record reviews facility staff do not accord dignity to a resident in care [R1] by grabbing and shouting at them to force them out of a transport car.

This posed a personal rights risk to 1:5 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: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3