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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604586
Report Date: 08/30/2026
Date Signed: 08/31/2026 07:01:31 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/31/2026 07:01 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ELDERLY HAVENFACILITY NUMBER:
374604586
ADMINISTRATOR/
DIRECTOR:		AKHTER-RAHMAN, SYEEDA SELIFACILITY TYPE:
740
ADDRESS:10163 EMBASSY WAYTELEPHONE:
(858) 935-9062
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 5DATE:
08/30/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Mohammad RahmanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. Upon arrival, LPA was greeted by Care Staff Zenia Valdehueza. Administrator Mohammad Rahman joined the visit shortly afterward. LPA discussed the purpose of the visit with both staff. The facility license reflects a maximum capacity of six (6) non-ambulatory residents.

LPA and Administrator Rahman toured the interior and exterior of the facility and inspected each room. The facility was bedrooms and livngroom room were observed to be clean, sanitary, and in good repair. Pathways were clear of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment for dining, laundry, visitation, meetings, and resident activities. Food supplies were inspected and found to include at least two (2) days of perishable items and seven (7) days of non-perishable items..

Cooking and dining equipment were available and operable. No toxic chemicals or poisons were accessible to residents. No pools or other bodies of water were observed on the premises. Carbon monoxide detectors, emergency lighting, and the facility telephone were operational. Fire extinguishers were serviced within the past twelve (12) months and first aid kits were complete. Required postings were observed in visible areas of the facility.

Simon Jacob
Amy Rodgers
DATE: 08/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2026
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/31/2026 07:01 AM - It Cannot Be Edited


Created By: Amy Rodgers On 08/30/2026 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2026
Section Cited
CCR
87555(b)(31)(B)

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(B)The following food service requirements shall apply: (31)(B)B) In facilities not using mechanical means...as the addition of a sanitation agent to the final rinse water.
This requirement was not met, as evidenced by:
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The licensee shall immediately implement an approved sanitizing method for all hand washed dishes. The licensee shall submit photos of properly set up sanitizing procedures by POC and a written plan confirming ongoing compliance and CCLD approved trainig by POC.
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Based on observation and interview, the licensee failed to ensure that dishes and utensils were properly disinfected after handwashing for 5 of 5 residents (R1–R5). This poses an immediate health and safety risk to residents in care.
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Type A
09/01/2026
Section Cited
CCR87555(b)(27

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87555 General Food Service Requirements(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
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The licensee shall immediately clean and sanitize all contaminated kitchen surfaces and dishware, discard any items that cannot be safely sanitized, and contact a licensed pest control service. Proof of pest control service, sanitation logs, and photos of cleaned areas shall be submitted to LPA by POC date.
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Based on observation and interview, the licensee did not ensure the kitchen and food service areas were maintained free of rodents droppngs for 5 of 5 residents (R1–R5). This poses an immediate 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/31/2026 07:01 AM - It Cannot Be Edited


Created By: Amy Rodgers On 08/30/2026 at 12:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2026
Section Cited
CCR
87555(b)(18)

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87555(b)(18) – General Food Service Requirements (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.
This requirement was not met, as evidenced by:
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The licensee shall ensure all food service staff receive training through an approved CCLD training vendor covering proper dish sanitizing procedures, food safety practices, vermin identification, and kitchen sanitation requirements.
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The licensee did not ensure food service personnel were adequately trained to meet the needs of 5 of 5 residents (R1–R5), which poses a potential health and safety risk to residents in care (R1-R5)
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The licensee shall submit documentation of completed vendor provided training, including certificates and proof of completion, to LPA by POC Date
Type B
10/01/2026
Section Cited
CCR87465(h)(1)

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The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers..
This requirement was not met, as evidenced by:

This requirement is not met as evidenced by:
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The licensee shall ensure all staff responsible for medication assistance receive training through an approved CCLD training vendor covering proper medication handling, administration from original pharmacy containers, and
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Based on observation and interview, the licensee did not comply with the section cited above in 5 of 5 persons which poses a potential health and safety risk to residents in care (R1-R5)
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prohibitions against pre-pouring medications. The licensee shall submit documentation of completed vendor-provided training, including certificates and proof of completion, to LPA by POC 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2026 07:01 AM - It Cannot Be Edited


Created By: Amy Rodgers On 08/30/2026 at 12:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2026
Section Cited
CCR
87470(a)(2)(A)

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(A) Surfaces such as floors, chairs, toilets.... These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.
This requirement was not met, as evidenced by:
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The licensee shall immediately stop the practice of rinsing and draping soiled linen outside. The licensee agrees to obtain infection control training from an approved outside/CCLD vendor. All staff shall be re-trained on safe practices for handling of
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Based on observation and interview, the licensee did not ensure infection control practices were maintained. Staff were observed rinsing soiled linens outside and draping them over bushes, which poses an immediate health and safety risk to 5 of 5 residents (R1–R5).
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changing, transporting, and laundering contaminated resident items, including linens, clothing, and personal materials. The licensee shall submit schedule of vendor-provided training to LPA by POC date and Provide proof of training 10-1-2026
Type A
09/01/2026
Section Cited
CCR87307

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87307Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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Licensee shall immediately stop the practice of staff sleeping in the garage. All staff shall sleep only in areas approved under the facility’s fire clearance. Licensee shall submit photos showing the garage is used as store room and office only by POC.
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Based on observation, the licensee did not ensure living accommodations matched the approved facility function. Staff were observed using the garage as a sleeping area, although the garage is not approved for habitation under the facility’s fire clearance. This poses a potential health and safety risk for 5 of 5 residdents
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/31/2026 07:01 AM - It Cannot Be Edited


Created By: Amy Rodgers On 08/30/2026 at 12:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2026
Section Cited
CCR
87468.1(a)(1)

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87468.1(a)(1) – Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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The licensee shall immediately stop the practice of using cut shirts and ensure all residents are offered dressing in appropriate, intact clothing that protects dignity. All staff will receive personal-rights training through an approved CCLD vendor.
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Based on observation and interview, the licensee did not ensure residents were accorded dignity. Residents were observed either partially undressed, in briefs only, or wearing altered clothing cut up the back, which poses an immediate personal rights risk for 3 of 5 residents (R1–R3).
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Proof of training and confirmation that residents are properly dressed will be submitted to LPA by POC date

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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ELDERLY HAVEN
FACILITY NUMBER: 374604586
VISIT DATE: 08/30/2026
NARRATIVE
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(continued from LIc809)

Staff interviewed reported adequate staffing and access to needed supplies. Staff demonstrated general knowledge of daily care routines; however, gaps were noted in medication procedures. Confidential resident and staff records were reviewed and were stored in locked areas. During the required annual visit, LPA reviewed resident records, medication storage, and staff training.

LPA observed five (5) pre-poured medication in locked medication closet for residents #1- Resident #5 (R1–R5), Staff #1 confirmed during interview that staff pre-pour medications before administration. Further inspection of kitchen revealed that dishes were washed using soap and water only, with no sanitizing step. Rodent droppings as well as dead cockroaches were observed inside storage cabinets. During the inspection, LPA also observed staff rinsing contaminated linens outdoors using a garden hose. This practice does not meet infection control requirements for safe handling of soiled materials and poses an immediate health and safety risk. LPA observations further revealed the garage showed a bed, dresser, clothing, and personal belongings. Staff interviews did not confirm sleeping in the garage. However, the garage is not an approved living area under the facility’s fire clearance. Personal rights concerns were observed for residents R1–R3. Residents were observed partially undressed, wearing only briefs, or wearing shirts cut up the back. Care plans contained no documentation supporting the practice.

Based on observations, interviews, and record review, deficiencies are cited today per California Code of Regulations, Title 22. Deficiencies are documented on the attached LIC 809-D pages. Plans of Correction (POCs) were jointly developed with the Administrator.

An exit interview was conducted with Administrator Mohammad Rahman, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Amy Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2026
LIC809 (FAS) - (06/04)
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