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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604277
Report Date: 11/22/2024
Date Signed: 11/22/2024 12:43:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20241107094027
FACILITY NAME:SAFE HARBOR ELDER CAREFACILITY NUMBER:
374604277
ADMINISTRATOR:RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:3301 LOMAS SERENAS DRIVETELEPHONE:
(619) 791-5495
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:6CENSUS: 6DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator Nikita MundhadaTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility staff recorded resident without consent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude the complaint investigation regarding the allegation listed above. LPA was granted entry and met with Administrator Nikita Mundhada who was informed of the purpose for the visit. The investigation consisted of observations, interviews, and records review.

Regarding the allegation “Facility staff recorded resident without consent”, it was reported photographs and videos were taken of Resident One (R1) by staff without R1’s consent. Interview conducted with R1 revealed R1 has told staff they do not want to be recorded or have their picture taken. Interview with Administrator Nikita Mundhada revealed photos and recordings are taken of R1 and the residents to document incidents and injuries so they can send the recordings or photos to R1’s medical team and social worker at Program of All-Inclusive Care for the Elderly (PACE). Record review of R1’s Physician’s Report documents R1 is able to communicate their own needs.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 5
Control Number 18-AS-20241107094027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAFE HARBOR ELDER CARE
FACILITY NUMBER: 374604277
VISIT DATE: 11/22/2024
NARRATIVE
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 Record review of R1’s Admissions Agreement has a “Consent to Photograph” section signed by R1 in which authorizes “photographing portions of resident’s body to document skin condition”. Interview with staff reported they ask R1 and the other residents for their consent prior to taking a photo or recording so they can send it to Administrator Mundhada. Interview with residents reported witnessing staff take pictures of R1 after R1 had verbally told staff “no”.

Based on LPA’s interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22, Division 06, Chapter 08), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report, deficiency page LIC 9099-D, LIC 811, and appeal rights was provided to Administrator Mundhada.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20241107094027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAFE HARBOR ELDER CARE
FACILITY NUMBER: 374604277
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidence by:
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Licensee will ensure staff are trained and understand the Personal Rights of the residents and will submit proof of staff training to LPA by the plan of correction date 11/29/2024. Licensee reported they staff will no longer take photos of R1.
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Based on interviews and record review, Licensee did not ensure Resident One (R1)'s personal rights when taking a photograph or recording of R1 with their consent which poses a personal rights, health, and safety risk to the residents 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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20241107094027

FACILITY NAME:SAFE HARBOR ELDER CAREFACILITY NUMBER:
374604277
ADMINISTRATOR:RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:3301 LOMAS SERENAS DRIVETELEPHONE:
(619) 791-5495
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:6CENSUS: 6DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator Nikita MundhadaTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility staff did not assist resident after fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude the complaint investigation regarding the allegation listed above. LPA was granted entry and met with Administrator Nikita Mundhada who was informed of the purpose for the visit. The investigation consisted of observations, interviews, and records review.

Regarding the allegation “Facility staff did not assist resident after fall” it was reported Staff Two (S2) had left Resident One (R1) on the floor for an extended amount of time after a fall. Interview with R1 reported they had fallen in their room and S1 left R1 on the floor for approximately one (1) hour. R1 reported they were screaming for help and Staff Two (S2) had walked into the room to assist up off the floor. Interview with Administrator Nikita Mundhada revealed on 11/04/2024, R1 had an unwitnessed fall that had caused a head injury. Due to head injury, Administrator Mundhahda and staff informed R1 the paramedics needed to be contacted. R1 denied emergency medical services. Administrator Mundhada contacted PACE to arrange a pickup for R1 to go to the clinic to get medical treatment.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20241107094027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAFE HARBOR ELDER CARE
FACILITY NUMBER: 374604277
VISIT DATE: 11/22/2024
NARRATIVE
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 S1 denies leaving R1 on the floor on 11/04/2024 for an extended amount of time and had notified S2 and Administrator Mundhada of the unwitnessed fall to provide R1 with assistance. S1 reported R1 is a two person assist and staff also utilize a Hoyer lift to assist R1. Interview with S1 and Staff Two (S2) revealed they do not leave residents on the floor after a fall for an extended amount of time. Interview with staff reported when a resident has an unwitnessed fall, they assess the resident for injuries. If emergency medical services are needed, the staff will notify Administrator Mundhada and contact 911. Interview with two (2) additional residents reveal they have witnessed S1 and additional staff help assist R1 when they fall and have never observed R1 on the floor for an extended amount of time.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report and LIC 811 was provided to Administrator Mundhada.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5