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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604586
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:04:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/13/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20221013151539
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: 5DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee, Mohammad RahmanTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Licensee did not take measures to keep the facility free of bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced complaint investigation visit. LPA was greeted and allowed entry into the facility and allegations mentioned above with Licensee, Mohammad Rahman.

During the investigation, LPA toured the facility, requested records, and interviewed staff, residents, and outside sources. It was alleged the licensee did not take measures to keep the facility free of bugs. It was reported the facility had roaches since August 2022 and measures have not been taken to keep the facility free of roaches. Administrator’s interview revealed a professional exterminator, sprayed the facility in either June or July 2022 and again in October 2022. Administrator confirmed there were baby roaches observed in the kitchen and outside in October 2022. Administrator stated once the roaches were observed in October 2022, the facility staff sprayed the inside and outside of the house. Administrator stated it was reported to her that a baby roach was observed in a resident’s room and the room was cleaned by staff. Staff interviews revealed the pest control only sprayed because they said in order to better exterminate the facility the residents would have to be out of the facility for a minimum of four (4) hours and some residents cannot sustain that. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
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-20221013151539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586
VISIT DATE: 11/15/2022
NARRATIVE
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For now, the pest control company will continue to spray every three (3) months or more if needed. Outside source interviews revealed live roaches were observed on Resident #1 (R1)’s wheelchair and in the cup storing their dentures. Outside source correspondence indicated the licensee was made aware of the roaches on 08/14/22. However, the professional exterminator was not called out until 10/15/22. The facility continued to have roaches from August to October 2022 and the proper measures were not taken to keep the facility free of roaches. Resident interviews confirmed the facility has live roaches and roaches have been found in the drawers. On 10/17/22, LPA observed live roaches in the facility and dead roaches in resident drawers. Additional outside sources revealed observing live roaches in the kitchen, bathroom, living room, and resident’s room from August through October 2022. Facility records indicated the professional pest control Service Agreement began in October 2022, and not in August 2022 when the licensee was initially made aware of the roaches.

Based on observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Licensee, Mohammad Rahman whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20221013151539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee had the facility sprayed by a professional exterminator on 10/15/22 and provided proof of service. The licensee has agreed to continue to have the facility remain free of roaches/bugs by using the professional exterminator when necessary. POC corrected.
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Based on observations and interviews, the licensee did not ensure the facility was free of roaches for (R1) 1 out of 5 residents. This posed a potential health and safety risk to 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3