Poway Elder Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself to Licensee Rathi and was granted entry into the facility. The facility is licensed for six (6) residents;of which all can be non-ambulatory, 1 resident may be bedridden, and 3 may be receiving Hospice services. During today's visit all 6 residents were present. LPA Correia conducted a resident records review and conducted a partial facility tour. An overall inspection of the facility began today however due to time constraints LPA was unable to complete the visit and will return later to conduct the remaining portion of this inspection. No deficiencies were cited during today's visit. This report was discussed with Licensee Rathi A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report.the state’s words, verbatim · CDSS document, Nov 13, 2025

Allegation investigated: Licensee did not give resident nutritional supplement as prescribed.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Victor Loera. LPA then met and discussed the purpose of the visit with Co-Administrator Nikita “Nikky” Mundhada, who arrived shortly after. The Complainant alleged that Licensee did not give Resident #1 (R1) their nutritional supplement as prescribed. CCLD’s investigation involved a welfare check on R1, multiple unannounced facility visits/tours, and interviews of relevant facility staff, residents, and outside sources. The Department also reviewed pertinent facility care records, outside medical records, and E-mail correspondence regarding R1’s care. [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] During the complaint allegation time frame, R1 was being followed by an outside healthcare management agency. R1’s primary care physician (PCP), dietician, and other medical professionals were based at this agency. The Complainant claimed that on 01/16/2025, PCP changed R1’s order/prescription for Glucerna nutritional supplement from one (1) bottle per day to two (2) bottles per day. They said that from 01/16/2025 through 02/12/2025, there were days Licensee gave R1 one (1) bottle instead of the prescribed two (2). Interviews of facility manager and multiple caregivers unanimously showed: As of the commencement of CCLD’s investigation on 02/20/2025, all staff were under the impression that R1 was supposed to receive just one (1) bottle of Glucerna per day in the evening, to be given only if their blood sugar was less than 300 mg/dL. All staff interviewed said they were following this order. All staff interviewed also denied the existence of an order for R1 to take two (2) bottles of Glucerna per day. LPA reviewed dated and time-stamped electronic orders from R1’s healthcare management agency, which showed: Prior to the complaint allegation time frame, R1 was indeed prescribed just (1) bottle of Glucerna per day, to be given only if their blood sugar was less than 300 mg/dL. While R1 did undergo a nutritional reassessment by their dietician on 01/15/2025, the evidence did not show that there was yet an active doctor’s order changing their Glucerna regimen during the complaint allegation time frame, let alone that such an change order (if it even existed then) was successfully transmitted/communicated to Licensee during the complaint allegation time frame. Rather, the healthcare management agency's first electronic recording of the doctor's order to increase R1’s Glucerna to two (2) bottles per day appeared several days after CCLD commenced its complaint investigation. Facility staff followed this later order, as soon as it was received. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not give R1 their nutritional supplement as prescribed. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Co-Administrator Nikita “Nikky” Mundhada, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 08-AS-20250213114415

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Victor Loera. LPA then met and discussed the purpose of the visit with Co-Administrator Nikita “Nikky” Mundhada, who arrived shortly after. Interviews of multiple staff and multiple outside sources unanimously corroborated that caregiver Staff #1 (S1) was unable to speak English. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Outside sources expressed this was an impediment to person-centered communication with residents who have cognitive impairment. LPA met S1 in person and observed that they were unable to communicate in English, even at a basic, conversational level. Both facility administrators stated that they usually have an English-speaking staff working alongside S1, and that S1 knows how to use a language translation app on their personal smart phone. LPA observation and staff interviews showed there were six (6) residents in care, of whom one (1) was bilingual English/Spanish, one (1) spoke only Mandarin, and the remaining 4 had English as their primary language and did not speak Spanish. The preponderance of evidence still showed S1 was unable to effectively/efficiently communicate with a majority of residents in care. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. LPA also provided Technical Assistance (TA) to Licensee regarding storage of nutritional supplements and requirements related to diabetes care. An exit interview was conducted with Co-Administrator Nikita “Nikky” Mundhada, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Apr 18, 2025

87411 Personnel Requirements – General: “(d) All personnel shall…have...: (3) Skill and knowledge required to provide necessary care and supervision, including the ability to communicate with residents.” The requirement was not met, as evidenced by: Based on interviews and LPA observation, Licensee did not ensure that 1 of 5 active staff (S1) had the language skill, knowledge, and ability to communicate with 4 of 6 residents (Resident #1 through Resident #4). This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: As of the date of deficiency issuance, S1 is participating in an online educational course to help them learn English. By the POC due, Licensee agreed to E-mail to LPA an updated caregiver work schedule showing a replacement staff ready to take over S1’s shifts. [If S1 has acquired basic conversational English skills by that date, Licensee shall arrange for S1 to video call LPA for a one-on-one phone interview/examination.]

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted a Case Management visit to deliver an Amended Report for a visit conducted on August 29, 2024 and to clear a deficiency. LPA was granted entry by caregiver Regina Reyes Romero. LPA Lopez met with Administrator Nikita Mundhada and informed them the purpose of their visit. During today’s visit, LPA obtained Licensee’s signature on the amended report LIC 9099 dated (08/29/2024). Additionally, during the visit on 08/29/2024, the facility was issued a citation for having an inoperable refrigerator. During today’s visit, LPA checked the refrigerator, and it was cool to the touch. LPA was provided a photo of their gauge which read 40 degrees Fahrenheit. LPA observed the gauge located in the refrigerator which read 40.0 degrees F during today's visit. An exit interview was conducted and a copy of this report along with the Licensee’s Rights (LIC 9058 03/22) were provided to Administrator Nikita Mundhada at the conclusion of the visit. The signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 9, 2024

Allegation investigated: Licensee does not ensure that staff are adequately trained.

Licensing Program Manager (LPM) Lizzette Tellez, and Licensing Program Analysts (LPAs) Juliana Barfield and David Roman, conducted an unannounced visit to follow-up and deliver findings on the above-mentioned allegation. LPM and LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Staff Gilbert Covarrubias Flores. Administrator Nikita Mundhada shortly after joined the LPM and LPAs for the visit. It was alleged that Licensee does not ensure that staff are adequately trained. The Department's investigation consisted of review of pertinent records, interviews with staff, residents, and outside sources, and a tour of the facility. Investigation revealed that Resident #1 (R1), a resident with major neurocognitive disorder, resides at the facility. R1 is diagnosed with a medical condition for which blood sugar monitoring is needed. Review of R1's records and interviews revealed R1 is able to communicate their needs. Interviews with staff, outside sources, and residents did not support the allegation. Outside source interviews, including health professionals, revealed staff are provided guidance on how to respond to R1's blood sugar Unsubstantiated readings, whether high or low, in order to address health concerns. Interviews with staff revealed staff are provided on the job training regarding responding to blood sugar readings. Staff interviews demonstrated staff's knowledge in response to high or low blood sugar readings, and observation of R1 when they are not feeling well. Interviews with residents, including R1, did not reveal concerns regarding staff training or responsiveness to blood sugar readings. Review of records revealed staff are provided training regarding Restricted Health Conditions. Based on interviews and record review, there is insufficient evidence to prove the alleged violation occurred. Therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Nikita Mundhada, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 08-AS-20240906160613

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) David Roman, LPA Juliana Barfield, and Licensing Program Manager (LPM) Lizette Tellez, conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit by LPA J. Barfield. LPAs were welcomed by, House Manager, Gilbert Covarrubias, identified themselves to, Caregiver, Yolanda Rodriguez, and discussed the purpose of the visit. At a later time, during the tour of the facility, LPAs introduced themselves with Administrator, Nikita Mundhada. According to the facility’s license, the facility has a maximum capacity of six clients. However, the census was 4 of whom all may be non-ambulatory and one of which may be bedridden. LPA toured the interior and exterior of the facility and inspected each room. The facility was 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 facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to client. Medications were labeled, as required, and stored in locked areas. Water temperature was measured between 112 to 115 degrees F. No pools or bodies of water on the premises. Per Nikita Mundahada, no firearms or ammunition are kept at the facility. Carbon monoxide detector tested in the hallway, emergency lighting, and facility telephone were all working. Facility staff tested fire alarms in resident bedrooms at 11:30am. Fire extinguisher was present with a purchase date of 02/28/2024. First aid kit(s) were complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed made available via Administrators laptop. Staff records proved CPR/First Aid Training Certificates completed on S1 09/05/24, S2 completed certificate on 09/15/2024. LPA interviewed staff and residents. An exit interview was conducted with Designee, Yolanda Rodriguez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22), were provided during the visit.the state’s words, verbatim · CDSS document, Dec 4, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

Licensing Program Analyst’s (LPA’s) Carmen Lopez and Hanah Rodgers conducted a Case Management visit, to conduct an unannounced health and safety check for residents in care. LPA's identified themselves and were granted entry by Regina Reyes Romero, caregiver. LPA met with caregiver Reyes Romero and disclosed the purpose of the visit. Administrator Nikita Mundhada later arrived and joined the visit. During a complaint investigation on August 29, 2024, LPA observed that that the front door had the code lock door facing the inside of the facility. The facility was cited on a fire clearance issue during the investigation. LPA spoke with the Licensee Gaurav Rathi and informed them that the code lock would need to face the outside which Licensee ensured was completed. During today’s visit, LPA’s Lopez and Rodgers confirmed that the code locks faced the outside. No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator Nikita Mundhada and a copy of this report and Licensee/Appeal Rights (LIC 9058 3/22) were provided to the Administrator at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Sep 5, 2024

Allegation investigated: - Facility did not follow fire clearance - Facility staff locked resident in their room - Licensee does not ensure facility fridge is in good condition

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings for a complaint investigation. While at the facility LPA delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Administrator Nikita Mundhada. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Mundhada. The Department’s investigation consisted of interviews with staff and residents, records review of relevant documents pertinent to this investigation, and LPA observations. On August 20, 2024, it was alleged that the facility did not follow their fire clearance, the facility staff locked resident in their room, and licensee did not ensure that the facility refrigerator was in good condition. It was specifically alleged that the facility did not follow their fire clearance. LPA observations, and staff and Administrator interviews confirmed that the passcode locks in hallways, that lead to the front door and kitchen, were used to prevent residents from accessing other areas throughout the night. “This is an amended version of the original report created on 08/29/24.” Substantiated On 08/27/24 and 08/29/24 the Department observed that a bike lock was used to secure the perimeter which is approved per the facility fire clearance. Staff interviews revealed that padlocks are also used throughout the interior of the facility for residents from wandering throughout the facility at night. One resident interviewed corroborated that they are locked in throughout the night with only access to the hallway and their room. Residents are locked in after 6:00 PM. Upon LPA’s entrance to the facility, the door had a padlock facing inside to use a pass code to exit the facility. Upon view of the hallway, there were two doorways that led to the front entrance and the kitchen. Both the doors had coded door handles. LPA observed that one room’s exit doors also was obstructed by a couch, and inoperable from both the interior and exterior. Per the Administrator, the couch was placed there at the residents and family's request. Further, an additional latch was observed installed, and locked on the outside of the door, preventing the exit inaccessible to the resident. Administrator said that there is an exit door located in room #4 for emergencies. A review of records revealed the facility fire clearance was approved for only delayed egress/secured perimeter/secured locked perimeter. It was specifically alleged that there was a client who was locked in their room. Interviews with staff were contradictory. A staff and Administrator said that they were unaware that the door’s lock was flipped. Administrator said that they do not use the lock and that they purchased the home that way. Other staff mentioned that the lock was not facing that way when a former resident lived there. Department records demonstrate the facility was licensed December 2021. On August 27, 2024, LPA toured the facility and observed that a lock for a resident’s room was facing outwards to be able to lock the room from the outside. The handle from the inside was a plain handle. The paint from the back plate of the handle, called the rosette, mounted to the door was peeling off. Prior to LPA’s exit, staff removed the latch from the door and demonstrated it to LPA. On August 29, 2024, LPA toured the facility and observed that the latch was put back on the door. Upon a second visit on August 29, 2024, LPA observed that the facility replaced the door handles to have no locks. It was specifically alleged that the facility refrigerator was not cold enough and was too warm for the food items. According to the Administrator, both gauges inside the refrigerator were broken. On August 27, 2024, LPA toured the facility and observed that the refrigerator had 2 analog refrigerator gauges. Gauge #1 indicated the temperature was in the “Danger Zone”. Gauge #2 measured the temperature in the red zone which said “Warm”. “This is an amended version of the original report created on 08/29/24.” LPA placed their arm into the refrigerator and felt that the temperature was warm to the feel. LPA placed their temperature thermometer into the refrigerator for approximately 35 minutes to obtain a better reading of the refrigerator’s temperature. Upon observation of the reading, the temperature read 48.6 degrees Fahrenheit (F) and 9.6 degrees Celsius (C) which is over the allowed temperature. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and resident interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D of this report. Civil penalties are being assessed and are noted on the attached to this report in the amount of $500.00. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Administrator Nikita Mundhada. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Administrator Mundhada at the conclusion of the visit. The signature below confirms the receipt of these documents. “This is an amended version of the original report created on 08/29/24.” They would like to be able to eat in the dining area with other residents, but overall the staff attend to them. Residents mentioned that the hallway doors are closed after dinner between 6 PM – 7 PM. Interview with staff said that the residents wander into the kitchen at night. Staff mentioned that usually residents sleep throughout the night after dinner and staff wake prior to the residents to opened doors around 7 AM and ready the residents for breakfast. Staff said there are some residents who are able to eat in the dining area but some who due to current decline in their conditions have been resting and having their meals in their room but are always welcomed to come out when they want. According to the Administrator and staff, staff do ask residents if they want to eat in the dining area but mostly opt to eat in their rooms. Administrator and staff said that there are two 12-hour shifts for staff. Administrator mentioned that they do have live-in staff and when one staff goes on their break, the other relieves them to care for the residents. Staff mentioned there are a total of two breaks for the shifts which are 30 minutes and a 3-hour break in between which staff tend to alternate to have a total of a 4-hour break during their 12-hour shift. Staff said that they tend to manage their workload when the residents nap, which is usually after their meals. A review of records revealed that there are two staff scheduled for Tuesday’s, Wednesday’s, and Thursday’s. Throughout the weekend there are three staff, from Thursday through Sunday. The Department received their fire clearance which approved the facility to have a secured perimeter/secured locked perimeter. On August 27, 2024, LPA observed that there were two staff at the facility. One was cooking and caring for residents while the other staff did not appear until later in the evening to assist. The facility was clean and sanitary. Residents were clean and well kempt. LPA observed that the facility had padlocks to two of the doors (which is being addressed in an allegation to this complaint) in the hallway which would prevent entry and exiting the area. Although there are padlocks on the doors, LPA observed that the facility staff were assisting residents with changes, meals, laundry, redirection, and other daily workloads while caring for the residents. It was specifically alleged that there are staff who are unable to communicate with residents. Interview with the Administrator mentioned that they currently have four (4) staff who regularly work there Monday through Sunday. As far as they are aware they have no issues with staff’s communication with residents. Resident interviews revealed that there is a staff person who had more difficulty speaking with residents but uses their phone to translate and vice versa. Both staff and residents have that communication method which thus far works, but there are other staff around as well. A review of records revealed that during the facility’s required Annual Inspection, two staff were interviewed and designated LPA had no issues with staff communication and understanding. One of the two staff interviewed are still employed at the facility. On August 27, 2024, LPA spoke with one staff who was more than able to understand and communicate with LPA. The second staff person was not able to speak with the LPA as they were assisting with residents’ changes. On August 29, 2024, LPA was able to speak with the second staff person in both English and Spanish. Staff communicated well with LPA in both languages. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and resident interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Administrator Nikita Mundhada. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Administrator Mundhada at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 08-AS-20240820083232

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Aug 29, 2024

Fire Clearance - All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal … this requirement was not met as evidence by: Based on interviews and observations, staff did not maintain the facility’s fire clearance by having padocked doors in their hallway which posed a potential safety risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: The door handles have been removed from both the interior doors of the hallway during today's visit on 08/29/2024. POC is deemed cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Aug 29, 2024

Personal Rights of Residents in All Facilities (a)(6) to leave or depart the facility at any time and not to be locked into any room, building, or on the facility premises by day or night … this requirement was not met as evidence by: Based on observations, staff did not protect the personal rights of the residents and had the locking mechanism onto the outside part of R1's door. This posed a potential safety and personal rights risk to 1 of 6 residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: The door handle for R1s room was replaced with one that does not lock during today's visit, 08/29/2024. This POC is deemed cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(21) · Plan of correction due date: Sep 12, 2024

General Food Service Requirements - Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C) … this requirement was not met as evidence by: Based on observations, staff did not ensure that the refrigerator was within the allotted temperature which posed a potential health risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: The Administrator purchased a new gauge and increased the temperature for the refrigerator from 3 to 5 to get cooler. Once the gauge is received, Administrator agreed to submit a photo of the refrigerator's temperature with the new gauge temperature to LPA by POC due date, 09/12/2024. If gauge reads warm temperature, Licensee will obtain a new refrigerator.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Nikita Mundhada, Licensee. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, one (1) of whom may be bedridden in room #4 only. During today’s inspection there were 6 residents in care. LPA and Licensee Nikita Mundhada 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. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. 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 client activities. Facility contained 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. No toxic chemicals/poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed staff and client records/files. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Nikita Mundhada, Licensee, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 12, 2023