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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 12:46:10 PM

Unsubstantiated


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
11/08/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20241108083534
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:
12:25 PM
MET WITH:Administrator Nikita MundhadaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff hit a resident
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 “Staff hit a resident”, it was alleged a staff member (S1) had smacked Resident One (R1) on their left hip. LPA’s interview with R1 revealed S1 had entered R1’s room to check on R1 during the night and “smacked me”. R1 reported they feel safe with S1 and R1 is not sure if the smack was intentional or an accident. R1 revealed they did not report the incident with S1 to Administrator Nikita Mundhada because they forget about the incident. LPA interviewed S1 who denied hitting R1 or the other residents in care. S1 reported they have not witnessed other staff members hit R1 or the other residents in care. Interview with Staff Two (S2) reported they did not witness S1 hit R1 or the other residents in care.
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: 1 of 2
Control Number 18-AS-20241108083534
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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 LPA conducted interviews with two (2) residents who reported they feel safe with S1 and the other staff members. Resident interviews revealed they have not witnessed S1 or the other staff hit R1 or the other residents in care. 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 Nikita 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 2