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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604485
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:47:51 AM

Document Has Been Signed on 12/09/2024 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:POWAY ELDER CAREFACILITY NUMBER:
374604485
ADMINISTRATOR/
DIRECTOR:		RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:14846 ESPOLA RDTELEPHONE:
(419) 377-9822
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Nikita Mundhada, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted a Case Management visit to deliver an Amended Report for a visit conducted on August 29, 2024 and to clear a deficiency. LPA was granted entry by caregiver Regina Reyes Romero. LPA Lopez met with Administrator Nikita Mundhada and informed them the purpose of their visit.

During today’s visit, LPA obtained Licensee’s signature on the amended report LIC 9099 dated (08/29/2024). Additionally, during the visit on 08/29/2024, the facility was issued a citation for having an inoperable refrigerator. During today’s visit, LPA checked the refrigerator, and it was cool to the touch. LPA was provided a photo of their gauge which read 40 degrees Fahrenheit. LPA observed the gauge located in the refrigerator which read 40.0 degrees F during today's visit.

An exit interview was conducted and a copy of this report along with the Licensee’s Rights (LIC 9058 03/22) were provided to Administrator Nikita Mundhada at the conclusion of the visit. The signature on this form confirms receipt of these documents.
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.

LIC809 (FAS) - (06/04)
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