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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604277
Report Date: 03/14/2025
Date Signed: 03/14/2025 01:05:47 PM

Document Has Been Signed on 03/14/2025 01:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAFE HARBOR ELDER CAREFACILITY NUMBER:
374604277
ADMINISTRATOR/
DIRECTOR:		RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:3301 LOMAS SERENAS DRIVETELEPHONE:
(858) 935-8818
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 6CENSUS: 6DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator, Nikita MundhadaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Nikita Mundhada who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (4) residents present.

The facility is a one story home with (4) bedrooms and (2) and a half bathrooms with attached garage. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed hand washing stations in the restrooms and kitchen, hand hygiene supplies and personal hygiene items for residents. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients in pantry closet. The smoke detector and carbon monoxide was operational, and the hot water temperature 115.3F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAFE HARBOR ELDER CARE
FACILITY NUMBER: 374604277
VISIT DATE: 03/14/2025
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (4) staff files and training. All staff have updated training along with CPR/First Aid Certification and required documents. LPA reviewed the Guardian roster, staff file and conducted interview with the Administrator which revealed (1) staff has been fingerprinted twice on 9/17/2024, and again on 2/3/2025 but did not receive a clearance from the department prior to working at the facility. Therefore a deficiency was cited and a civil penalty was issued. (4) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications for (2) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 12/16/2024. A technical note was issued for the licensee to document the names of staff participating in the drill. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit.

An exit interview was conducted where this report was reviewed and provided. The licensee and the administrator did not agreed with the assessment of the deficiency and refused to sign the report.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2025 01:05 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Janira Arreola On 03/14/2025 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAFE HARBOR ELDER CARE
FACILITY NUMBER: 374604277

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,. interview and records review, the licensee did not comply with the section cited above with (1) staff that was not cleared prior to working at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2025
Plan of Correction
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The administrator removed the staff immediately at the time of the visit. LPA provided the phone number and email where they can inquire on the status of the employee.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
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