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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604485
Report Date: 08/29/2024
Date Signed: 12/09/2024 11:33:03 AM

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
08/20/2024 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240820083232
FACILITY NAME:POWAY ELDER CAREFACILITY NUMBER:
374604485
ADMINISTRATOR:RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:14846 ESPOLA RDTELEPHONE:
(419) 377-9822
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Nikita Mundhada, AdministratorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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- Facility did not follow fire clearance
- Facility staff locked resident in their room
- Licensee does not ensure facility fridge is in good condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings for a complaint investigation. While at the facility LPA delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Administrator Nikita Mundhada. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Mundhada.

The Department’s investigation consisted of interviews with staff and residents, records review of relevant documents pertinent to this investigation, and LPA observations. On August 20, 2024, it was alleged that the facility did not follow their fire clearance, the facility staff locked resident in their room, and licensee did not ensure that the facility refrigerator was in good condition.

It was specifically alleged that the facility did not follow their fire clearance. LPA observations, and staff and Administrator interviews confirmed that the passcode locks in hallways, that lead to the front door and kitchen, were used to prevent residents from accessing other areas throughout the night.
“This is an amended version of the original report created on 08/29/24.”
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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 8
Control Number 08-AS-20240820083232
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: POWAY ELDER CARE
FACILITY NUMBER: 374604485
VISIT DATE: 08/29/2024
NARRATIVE
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On 08/27/24 and 08/29/24 the Department observed that a bike lock was used to secure the perimeter which is approved per the facility fire clearance. Staff interviews revealed that padlocks are also used throughout the interior of the facility for residents from wandering throughout the facility at night. One resident interviewed corroborated that they are locked in throughout the night with only access to the hallway and their room. Residents are locked in after 6:00 PM. Upon LPA’s entrance to the facility, the door had a padlock facing inside to use a pass code to exit the facility. Upon view of the hallway, there were two doorways that led to the front entrance and the kitchen. Both the doors had coded door handles. LPA observed that one room’s exit doors also was obstructed by a couch, and inoperable from both the interior and exterior. Per the Administrator, the couch was placed there at the residents and family's request. Further, an additional latch was observed installed, and locked on the outside of the door, preventing the exit inaccessible to the resident. Administrator said that there is an exit door located in room #4 for emergencies. A review of records revealed the facility fire clearance was approved for only delayed egress/secured perimeter/secured locked perimeter.

It was specifically alleged that there was a client who was locked in their room. Interviews with staff were contradictory. A staff and Administrator said that they were unaware that the door’s lock was flipped. Administrator said that they do not use the lock and that they purchased the home that way. Other staff mentioned that the lock was not facing that way when a former resident lived there. Department records demonstrate the facility was licensed December 2021. On August 27, 2024, LPA toured the facility and observed that a lock for a resident’s room was facing outwards to be able to lock the room from the outside. The handle from the inside was a plain handle. The paint from the back plate of the handle, called the rosette, mounted to the door was peeling off. Prior to LPA’s exit, staff removed the latch from the door and demonstrated it to LPA. On August 29, 2024, LPA toured the facility and observed that the latch was put back on the door. Upon a second visit on August 29, 2024, LPA observed that the facility replaced the door handles to have no locks.

It was specifically alleged that the facility refrigerator was not cold enough and was too warm for the food items. According to the Administrator, both gauges inside the refrigerator were broken. On August 27, 2024, LPA toured the facility and observed that the refrigerator had 2 analog refrigerator gauges. Gauge #1 indicated the temperature was in the “Danger Zone”. Gauge #2 measured the temperature in the red zone which said “Warm”.
“This is an amended version of the original report created on 08/29/24.”
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 08-AS-20240820083232
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: POWAY ELDER CARE
FACILITY NUMBER: 374604485
VISIT DATE: 08/29/2024
NARRATIVE
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LPA placed their arm into the refrigerator and felt that the temperature was warm to the feel. LPA placed their temperature thermometer into the refrigerator for approximately 35 minutes to obtain a better reading of the refrigerator’s temperature. Upon observation of the reading, the temperature read 48.6 degrees Fahrenheit (F) and 9.6 degrees Celsius (C) which is over the allowed temperature.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and resident interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D of this report. Civil penalties are being assessed and are noted on the attached to this report in the amount of $500.00.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Administrator Nikita Mundhada. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Administrator Mundhada at the conclusion of the visit. The signature below confirms the receipt of these documents.

“This is an amended version of the original report created on 08/29/24.”
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
08/20/2024 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240820083232

FACILITY NAME:POWAY ELDER CAREFACILITY NUMBER:
374604485
ADMINISTRATOR:RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:14846 ESPOLA RDTELEPHONE:
(419) 377-9822
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Nikita Mundhada, AdministratorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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- Insufficient staff to meet the residents care needs
- Facility staff are unable to communicate with residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings for a complaint investigation regarding the above-mentioned allegations. LPA identified herself and was granted entry by Administrator Nikita Mundhada. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Mundhada.

The Department’s investigation consisted of interviews with staff and residents, records review of relevant documents pertinent to this investigation, and LPA observations. On August 20, 2024, it was alleged that there was insufficient staff to meet the residents care needs; and facility staff are unable to communicate with residents.

It was specifically alleged that the facility staff locked the residents in the facility due to wandering. Interviews with residents said that they are being well taken care of but would like to have additional activities.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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 8
Control Number 08-AS-20240820083232
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: POWAY ELDER CARE
FACILITY NUMBER: 374604485
VISIT DATE: 08/29/2024
NARRATIVE
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They would like to be able to eat in the dining area with other residents, but overall the staff attend to them. Residents mentioned that the hallway doors are closed after dinner between 6 PM – 7 PM. Interview with staff said that the residents wander into the kitchen at night. Staff mentioned that usually residents sleep throughout the night after dinner and staff wake prior to the residents to opened doors around 7 AM and ready the residents for breakfast. Staff said there are some residents who are able to eat in the dining area but some who due to current decline in their conditions have been resting and having their meals in their room but are always welcomed to come out when they want. According to the Administrator and staff, staff do ask residents if they want to eat in the dining area but mostly opt to eat in their rooms. Administrator and staff said that there are two 12-hour shifts for staff. Administrator mentioned that they do have live-in staff and when one staff goes on their break, the other relieves them to care for the residents. Staff mentioned there are a total of two breaks for the shifts which are 30 minutes and a 3-hour break in between which staff tend to alternate to have a total of a 4-hour break during their 12-hour shift. Staff said that they tend to manage their workload when the residents nap, which is usually after their meals. A review of records revealed that there are two staff scheduled for Tuesday’s, Wednesday’s, and Thursday’s. Throughout the weekend there are three staff, from Thursday through Sunday. The Department received their fire clearance which approved the facility to have a secured perimeter/secured locked perimeter. On August 27, 2024, LPA observed that there were two staff at the facility. One was cooking and caring for residents while the other staff did not appear until later in the evening to assist. The facility was clean and sanitary. Residents were clean and well kempt. LPA observed that the facility had padlocks to two of the doors (which is being addressed in an allegation to this complaint) in the hallway which would prevent entry and exiting the area. Although there are padlocks on the doors, LPA observed that the facility staff were assisting residents with changes, meals, laundry, redirection, and other daily workloads while caring for the residents.

It was specifically alleged that there are staff who are unable to communicate with residents. Interview with the Administrator mentioned that they currently have four (4) staff who regularly work there Monday through Sunday. As far as they are aware they have no issues with staff’s communication with residents. Resident interviews revealed that there is a staff person who had more difficulty speaking with residents but uses their phone to translate and vice versa. Both staff and residents have that communication method which thus far works, but there are other staff around as well. A review of records revealed that during the facility’s required Annual Inspection, two staff were interviewed and designated LPA had no issues with staff communication and understanding. One of the two staff interviewed are still employed at the facility.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 08-AS-20240820083232
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: POWAY ELDER CARE
FACILITY NUMBER: 374604485
VISIT DATE: 08/29/2024
NARRATIVE
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On August 27, 2024, LPA spoke with one staff who was more than able to understand and communicate with LPA. The second staff person was not able to speak with the LPA as they were assisting with residents’ changes. On August 29, 2024, LPA was able to speak with the second staff person in both English and Spanish. Staff communicated well with LPA in both languages.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and resident interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.

The report was discussed, and an exit interview was conducted with Administrator Nikita Mundhada. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Administrator Mundhada at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20240820083232
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: POWAY ELDER CARE
FACILITY NUMBER: 374604485
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
87202(a)
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Fire Clearance - All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal … this requirement was not met as evidence by:
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The door handles have been removed from both the interior doors of the hallway during today's visit on 08/29/2024. POC is deemed cleared.
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Based on interviews and observations, staff did not maintain the facility’s fire clearance by having padocked doors in their hallway which posed a potential safety risk to 6 of 6 residents in care.
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Type B
08/29/2024
Section Cited
CCR
87468.1(a)(6)
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Personal Rights of Residents in All Facilities (a)(6) to leave or depart the facility at any time and not to be locked into any room, building, or on the facility premises by day or night … this requirement was not met as evidence by:
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The door handle for R1s room was replaced with one that does not lock during today's visit, 08/29/2024. This POC is deemed cleared.
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Based on observations, staff did not protect the personal rights of the residents and had the locking mechanism onto the outside part of R1's door. This posed a potential safety and personal rights risk to 1 of 6 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: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20240820083232
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: POWAY ELDER CARE
FACILITY NUMBER: 374604485
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
87555(b)(21)
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General Food Service Requirements - Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C) … this requirement was not met as evidence by:
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The Administrator purchased a new gauge and increased the temperature for the refrigerator from 3 to 5 to get cooler. Once the gauge is received, Administrator agreed to submit a photo of the refrigerator's temperature with the new gauge temperature to LPA by POC due date, 09/12/2024. If gauge reads warm temperature, Licensee will obtain a new refrigerator.
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Based on observations, staff did not ensure that the refrigerator was within the allotted temperature which posed a potential health risk to 6 of 6 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: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8