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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604485
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:18:32 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
09/06/2024 and conducted by Evaluator Juliana Barfield
COMPLAINT CONTROL NUMBER: 08-AS-20240906160613
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: 5DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Nikita MundhadaTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Licensee does not ensure that staff are adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Lizzette Tellez, and Licensing Program Analysts (LPAs) Juliana Barfield and David Roman, conducted an unannounced visit to follow-up and deliver findings on the above-mentioned allegation. LPM and LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Staff Gilbert Covarrubias Flores. Administrator Nikita Mundhada shortly after joined the LPM and LPAs for the visit.

It was alleged that Licensee does not ensure that staff are adequately trained. The Department's investigation consisted of review of pertinent records, interviews with staff, residents, and outside sources, and a tour of the facility. Investigation revealed that Resident #1 (R1), a resident with major neurocognitive disorder, resides at the facility. R1 is diagnosed with a medical condition for which blood sugar monitoring is needed. Review of R1's records and interviews revealed R1 is able to communicate their needs. Interviews with staff, outside sources, and residents did not support the allegation. Outside source interviews, including health professionals, revealed staff are provided guidance on how to respond to R1's blood sugar
Unsubstantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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 2
Control Number 08-AS-20240906160613
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: 12/04/2024
NARRATIVE
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readings, whether high or low, in order to address health concerns. Interviews with staff revealed staff are provided on the job training regarding responding to blood sugar readings. Staff interviews demonstrated staff's knowledge in response to high or low blood sugar readings, and observation of R1 when they are not feeling well. Interviews with residents, including R1, did not reveal concerns regarding staff training or responsiveness to blood sugar readings. Review of records revealed staff are provided training regarding Restricted Health Conditions. Based on interviews and record review, there is insufficient evidence to prove the alleged violation occurred. Therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Nikita Mundhada, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2