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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604586
Report Date: 08/26/2025
Date Signed: 08/26/2025 05:16:40 PM

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
08/26/2025 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20250826140115
FACILITY NAME:ELDERLY HAVENFACILITY NUMBER:
374604586
ADMINISTRATOR:AKHTER-RAHMAN, SYEEDA SELIFACILITY TYPE:
740
ADDRESS:10163 EMBASSY WAYTELEPHONE:
(858) 688-4667
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 4DATE:
08/26/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Caregiver Maribel Coloma and Licensee Dr. Mohammad RahmanTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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-Licensee had absence of supervision at facility.
-Licensee did not ensure medications were secured/locked.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Dang Nguyen and Ramin Hashemi conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Maribel Coloma. LPAs then met with Licensee Dr. Mohammad Rahman, who arrived later during the visit.

The Complainant alleged that Licensee had an absence of supervision at the facility, and that Licensee did not ensure that medications were secured/locked. CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of pertinent staff, residents, and outside sources. The Department also reviewed relevant care records.

[CONTINUED ON LIC 9099]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
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 3
Control Number 08-AS-20250826140115
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: ELDERLY HAVEN
FACILITY NUMBER: 374604586
VISIT DATE: 08/26/2025
NARRATIVE
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[CONTINUED FROM LIC 9099]

Interviews aligned to show that during the morning of 08/26/2025: Staff #1 (S1) was the sole employee on duty and left the premises. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] There was a period of at least one (1) hour when there were residents in care at the facility without on-duty staff present. While S1 was away, medications for one (1) resident were temporarily left atop the dining room table in plain view, unsecured and unlocked.

Based on interviews, a preponderance of evidence exists to show Licensee had an absence of supervision at the facility, and that Licensee did not ensure that medications were secured/locked. Both allegations were therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Since one of the deficiencies pertains to absence of supervision, a Zero Tolerance Violation Civil Penalty of $500 was also assessed/charged (refer to the attached LIC421-IM page). Since the medication deficiency is a repeat violation within a twelve (12) month period, a Repeat Violation Civil Penalty of $250 was also assessed/charged (refer to the attached LIC421-FC page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Licensee Dr. Mohammad Rahman, to whom a copy of this report, the LIC 9099-D page, the LIC421-IM page, the LIC421-FC page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250826140115
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: ELDERLY HAVEN
FACILITY NUMBER: 374604586
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by:
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Upon LPAs’ arrival, they verified that Licensee had staff present and caring for residents, resolving the immediate risk. Licensee agreed to perform written corrective action/counseling with S1 to reinforce to them that they shall not leave residents unsupervised, unless/until relieved by an on-duty coworker. Licensee also agreed to lead an inservice training with the larger staff team on the same topic and the importance of timely communicating tardiness to facility management. Licensee agreed to E-mail a copy of the corrective action document and the training sign-in sheet to LPA Nguyen, by 09/26/2025.
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Based on interviews, Licensee did not ensure that facility personnel at all times were sufficient in numbers to provide the services necessary to meet the needs of 4 of 4 residents (R1 through R4). This posed an immediate health and safety risk to persons in care.
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Type A
08/26/2025
Section Cited
CCR
87645(h)(2)
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87465 Incidental Medical and Dental Care: “(h) The following requirements shall apply to medications which are centrally stored: (2) 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 was not met, as evidenced by:
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Upon LPAs’ arrival, the medications in question had been secured, and LPAs saw that the facility’s medication cabinet was locked, resolving the immediate risk. Licensee agreed to perform written corrective action/counseling with S1 to reinforce to them that they shall not leave residents’ medications unlocked/unsecured. Licensee also agreed to lead an in-service training with the larger staff team on the same topic. Licensee agreed to E-mail a copy of the corrective action document and the training sign-in sheet to LPA Nguyen, by 09/26/2025.
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Based on interviews, Licensee did not ensure that centrally stored medications were kept in a safe and locked place that is not accessible to persons other than employees responsible for them. This posed an immediate health and safety risk to 4 of 4 residents (R1 through R4) 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: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3