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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604485
Report Date: 03/18/2025
Date Signed: 03/18/2025 07:12:37 PM

Document Has Been Signed on 03/18/2025 07:12 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
CCLD Regional Office, 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: DATE:
03/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Co-Administrator Nikita “Nikky” MundhadaTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Victor Loera. LPA then met and discussed the purpose of the visit with Co-Administrator Nikita “Nikky” Mundhada, who arrived shortly after.

Interviews of multiple staff and multiple outside sources unanimously corroborated that caregiver Staff #1 (S1) was unable to speak English. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Outside sources expressed this was an impediment to person-centered communication with residents who have cognitive impairment. LPA met S1 in person and observed that they were unable to communicate in English, even at a basic, conversational level. Both facility administrators stated that they usually have an English-speaking staff working alongside S1, and that S1 knows how to use a language translation app on their personal smart phone.

LPA observation and staff interviews showed there were six (6) residents in care, of whom one (1) was bilingual English/Spanish, one (1) spoke only Mandarin, and the remaining 4 had English as their primary language and did not speak Spanish. The preponderance of evidence still showed S1 was unable to effectively/efficiently communicate with a majority of residents in care. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. LPA also provided Technical Assistance (TA) to Licensee regarding storage of nutritional supplements and requirements related to diabetes care.

An exit interview was conducted with Co-Administrator Nikita “Nikky” Mundhada, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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Document Has Been Signed on 03/18/2025 07:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/18/2025 at 05:54 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: POWAY ELDER CARE
FACILITY NUMBER: 374604485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/18/2025
Section Cited
CCR
87411(d)(3)

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87411 Personnel Requirements – General: “(d) All personnel shall…have...: (3) Skill and knowledge required to provide necessary care and supervision, including the ability to communicate with residents.” The requirement was not met, as evidenced by:
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As of the date of deficiency issuance, S1 is participating in an online educational course to help them learn English. By the POC due, Licensee agreed to E-mail to LPA an updated caregiver work schedule showing a replacement staff ready to take over S1’s shifts. [If S1 has acquired basic conversational English skills by that date, Licensee shall arrange for S1 to video call LPA for a one-on-one phone interview/examination.]
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Based on interviews and LPA observation, Licensee did not ensure that 1 of 5 active staff (S1) had the language skill, knowledge, and ability to communicate with 4 of 6 residents (Resident #1 through Resident #4). This posed a potential personal rights risk to persons 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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