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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604586
Report Date: 08/12/2025
Date Signed: 08/13/2025 08:10:49 AM

Document Has Been Signed on 08/13/2025 08:10 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:ELDERLY HAVENFACILITY NUMBER:
374604586
ADMINISTRATOR/
DIRECTOR:		AKHTER-RAHMAN, SYEEDA SELIFACILITY TYPE:
740
ADDRESS:10163 EMBASSY WAYTELEPHONE:
(858) 688-4667
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 4DATE:
08/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Licensee, Mohammad Rahman TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Revelyn Ibera. Licensee, Mohammad Rahman and Administrator, Syeeda Seli Akhter-Rahman.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was sanitary, but needs repair. The fridge and freezer had dead insects and debris. Foods were not labeled and dated. The hot water for the sink in restroom #1 is not working, the shower mat was molded, the shower needs repair as far as the walls and crevices. Restroom #2's ceiling fan is making a loud noise and the shower walls and crevices needs to be repaired. Licensee was advised an updated dementia plan was needed along with an addendum to the plan of operation to include video surveillance. Disaster drills are being conducted but not documented correctly.

Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and toilets, and showers were in working order. However, the sliding door screens are not flush to the frames/bases, all need to be replaced or repaired. There were extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 110 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, but not stored in locked areas. There was insulin and suppositories in the fridge, and the garage had medications belonging to a caregiver, not locked. The licensee explained the insulin was in an unidentified package, made unknown it was insulin and is not being used. Also, the suppositories are not being used. The licensee explained the residents are monitored and do not enter the kitchen area, removing any immediate threat. LPA was able to confirm the medications were not noticeable and had to be pointed out by staff. Also, there were expired medications belonging to residents that no longer resided in the facility but the cabinet was locked.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Natasha Persaud
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586
VISIT DATE: 08/12/2025
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No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was incomplete. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. The licensee explained the residents and still working with the families to complete the required documentation. Confidential records were stored in locked areas. The licensee requested to increase their bedridden status. LPA printed the application and assisted with completion.

Deficiencies were observed or cited during today's annual inspection, along with Technical Advisories. An exit interview was conducted with Licensee, Mohammad Rahman to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Natasha Persaud
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2025 08:10 AM - It Cannot Be Edited


Created By: Natasha Persaud On 08/12/2025 at 01:35 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: ELDERLY HAVEN
FACILITY NUMBER: 374604586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews the licensee did not comply with the section cited above in 4 out of 4 residents [R1-R4] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Licensee stated all repairs will be made by POC due date.
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not ensure medications were centrally stored and made inaccessible to 2 of out 4 residents [R1-R4]. which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Licensee stated he locked the insulin and suppositories during the visit. Licensee will keep the insulin and suppositories in the fridge located in the locked garage. The garage doorknob will be replaced with a lock and key.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Natasha Persaud
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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