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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604586
Report Date: 09/04/2025
Date Signed: 09/05/2025 08:24:20 AM

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
08/29/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250829161121
FACILITY NAME:ELDERLY HAVENFACILITY NUMBER:
374604586
ADMINISTRATOR:AKHTER-RAHMAN, SYEEDA SELIFACILITY TYPE:
740
ADDRESS:10163 EMBASSY WAYTELEPHONE:
(858) 935-9062
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 4DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Mohammad Rahman TIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff yelled at resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Staff, Revelyn Ibera. Licensee, Mohammad Rahman and Administrator, Syeeda Seli Akhter-Rahman arrived during the visit.

During today's visit, LPA briefly toured the facility, reviewed records, interviewed staff and residents. It was alleged staff yelled at resident in care. It was reported a male staff yelled "shut up" at a resident due to the resident asking repeated questions. The resident that was allegedly yelled at has a Major Neurcoginitive Disorder. The resident was interviewed but due to the cognitive impariment, the interview was unsuccessful. Interviews with staff revealed they have not witnessed any caregivers yelling at staff or telling them to shut up. Residents interviewed also confirmed they have not witnessed staff yell or tell any residents to shut up. A review of records indicated the male staff member has receivd abuse training on file. Outside sources were interviewed and also stated they have not witnessed staff yelling or tell residents to shut up.Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 2
Control Number 08-AS-20250829161121
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: 09/04/2025
NARRATIVE
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During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Mohammad Rahman whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2