374603715-9-26-2025-08-AS-BCHN-DM2U2A-20251001151134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603715
Report Date: 09/26/2025
Date Signed: 09/26/2025 10:58:43 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
06/21/2024 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 08-AS-20240621145032

FACILITY NAME:	HARBORVIEW SENIOR ASSISTED LIVING		FACILITY NUMBER:	374603715
ADMINISTRATOR:	SETTINERI, JEFFREY		FACILITY TYPE:	740
ADDRESS:	2360 ALBATROSS STREET		TELEPHONE:	(619) 233-8382
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92101
CAPACITY:	30	CENSUS: 24	DATE:	09/26/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Genoveva Guerrero		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in a resident's elopement and injury
Staff did not provide resident’s records to resident’s authorized representative

INVESTIGATION FINDINGS:

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On 9/26/2025, LPA Grace Donato conducted a telephone interview to the facility to deliver findings. LPA spoke with Genoveva Guerrero and explained the purpose of the call.

Regarding the allegation of Staff did not provide adequate supervision resulting in a resident's elopement and injury, Reporting party (RP) stated that a resident (R1) was admitted 4-5 days prior to the incident and when admitted the facility was aware of R1’s history of dementia and his/her tendencies to flee. On 2/6/24, R1 exited through a staff door and no other details are known such as how far R1 went, how long R1 was missing, and who found R1. All that is known is that R1 managed to get on top of some rocks, fell and fractured R1s left wrist.
During the course of the investigation, staff members were interviewed, photos obtained, and records were reviewed.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240621145032

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: HARBORVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374603715
	VISIT DATE: 09/26/2025

NARRATIVE

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S1 and S2 stated R1 was a very complicated resident. S1 stated R1 always said he/she had to leave the facility to go with R1s son and when staff would try and redirect R1, R1 would become upset and hit staff with a cane and say mean things to them in Spanish. S2 stated staff had to rotate constantly when dealing with R1 because they noticed R1 would become a bit calmer when R1 would see a new face and didn’t like dealing with the same staff member the whole day.

On 02/06/2024, S1 was working his/her shift as a MedTech and preparing medications to pass out when S1 saw R1 walking toward the front door. S1 told R1 to not go outside, and R1 proceeded to walk out the front door acting like R1 didn’t hear what S1 said. S1 went after R1 but before doing so S1 needed to secure the medication cart and lock it before going outside. S1 said when R1 finally went out the front door, S1 told R1 to come inside, and R1 turned around and began swinging his/her cane toward S1. S1 said as R1 was swinging the cane facing S1, R1 was also walking backwards and suddenly R1 tripped over R1s own feet and fell to the floor landing on his/her left arm.

S1 said she did a head-to-toe assessment on R1 and also called for help over the radio. S1 said R1 said he/she had no pain on his/her body or legs. S1 mentioned that S2 arrived and they helped R1 up onto a patio chair and that’s when R1 started complaining of wrist pain and S1 called S4 to come. S1 told me once S4 came, S4 decided to call 911 to get R1’s injuries further checked out and medics arrived and transported R1 to the hospital where R1 was later diagnosed with a fractured left wrist.

S3 and S5, stated the complaint received about R1 eloping outside the facility is false. S5 stated the facility has a secure perimeter and staff knew R1’s whereabouts the whole time leading up to his/her fall. S3 added there are no rocks large enough to climb on facility grounds and there were no rocks near where R1 had a fall.

Based on photos obtained, the facility has a facility fence preventing residents to go out of the facility without assistance. There were no rock formations that would make the residents climb and cause injury.

Based on records review, according to resident appraisal dated 2/1/2024, R1 is able to ambulate with the help of a cane.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240621145032

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: HARBORVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374603715
	VISIT DATE: 09/26/2025

NARRATIVE

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For the allegation of Staff did not provide resident’s records to resident’s authorized representative, RP stated that a family member (F1) has requested information from the facility administrator and believes they are withholding information. In addition, F1 requested to view camera footage but was told that the cameras were not operational and is not being given full disclosure of the incident or full access to R1’s files.

According to S3, on the day of R1s accident as well as the times F1 went to the facility, F1 asked how the incident occurred and each time F1 was told how R1 fell, and staff never avoided telling F1 anything. S3 stated no information was withheld from F1 and they had no reason to lie to F1 or not tell him/her what occurred. S3 said F1 asked for video surveillance of the incident, and they told him/her they didn’t have any footage of the fall because their cameras don’t record and are only live cameras.

S3 said F1 never came to the facility asking for R1s admission agreement and if F1 did, they would have no problem giving it. S3 said a copy was provided to F1 at the beginning. S1 also added that days after the incident F1 came to the facility to collect R1s belongings and F1 had asked for a copy of R1s contract. S1 said at the time S3 and S4 were not at the facility and advised F1 that S1 couldn’t get a copy at the moment but if F1 came back when the managers were present, they will gladly provide that to F1. S1 said he/she even mentioned emailing or giving S4 a call regarding the contract and maybe S4 would be able to email it over.

There were several attempts to contact RP and F1 but never received a response.

Based on interviews, records review and observations, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and a copy is provided.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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