<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604586
Report Date: 08/28/2024
Date Signed: 08/29/2024 08:01:02 AM


Document Has Been Signed on 08/29/2024 08:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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: 4DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee, Syeeda Akhter-Rahman TIME COMPLETED:
06:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Revelan Ibera. Licensee, Syeeda Akhter-Rahman arrived during the visit.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The sink in bathroom #2 has a leak. However, the licensee has already contracted an outside source for repairs. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 106 F..

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were toxic chemicals/poisons accessible to residents. LPA observed chemicals were accessible under the kitchen sink and in the garage. There was a lock on the kitchen cabinet under the sink but it was not locked. Medications were labeled, as required but not locked. A lock was present on the medication closet but it was not locked. The facility has a resident that walks around the facility independently.

No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Continued on an LIC 809C.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/28/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Also, required staff training was not documented. Confidential records were stored in locked areas.

Deficiencies were observed or cited during today's annual inspection. Also, Advisory Notes were issued. An exit interview was conducted with the licensee to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/29/2024 08:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in 1 out of 4 [R1] residents, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
1
2
3
4
Licensee stated she will conduct In-Service training regarding locking medications and submit proof of training by POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if
readily available to clients shall be stored where inaccessible to clients.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in 1 out of 4 [R1] residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
1
2
3
4
Licensee stated she will conduct In-Service Training with staff regarding ensuring chemicals are inaccessible. Licensee stated she will submit proof of training by POC due date.
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: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3