Inspection Reports for Point Loma Elder Care
3941 Liggett Dr, San Diego, CA 92106, United States, CA, 92106
Back to Facility ProfileInspection Report Summary
Most inspections of this facility found no deficiencies, with the most recent reports from October 8, 2025, showing full compliance and no issues. However, earlier complaint investigations substantiated some concerns related to resident care, including neglect resulting in a stage 4 pressure injury, leaving a resident in soiled clothing, and lack of supervision, each resulting in a $500 civil penalty assessed in October 2024. Another substantiated complaint in late 2023 involved staff failing to provide required assistance to a resident who fell and sustained minor injuries. Several other complaint investigations were unsubstantiated, including allegations of staff misconduct and inadequate meals. The facility appears to have improved over time, with recent annual inspections consistently clean and no new deficiencies noted.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Oct 8, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with all licensing requirements. No deficiencies were issued during the inspection. The facility was clean, safe, and well-maintained with all required equipment and documentation in place.
Report Facts
Facility capacity: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the inspection |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
| Vinit Rathi | Facility Manager | Met with Licensing Program Analyst during inspection |
| Niki Mudhada | Administrator | Present during inspection and exit interview |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Oct 8, 2025
Visit Reason
Licensing Program Analyst Iby Strong conducted an unannounced quarterly Case Management/Legal Non-Compliance visit to evaluate the licensee's ongoing compliance with the requirements described in LIC9111 and the terms of a compliance plan agreed upon on January 22, 2025.
Findings
The facility was clean, safe, and in good repair with current and complete records. No immediate health or safety concerns were observed, and no deficiencies were issued during this compliance visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the unannounced quarterly Case Management/Legal Non-Compliance visit. |
| Nikita Mundhada | Administrator | Met with Licensing Program Analyst during the inspection and participated in the exit interview. |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Jan 21, 2025
Visit Reason
An unannounced Case Management visit was conducted by Licensing Program Analyst Sabel Martinez to tour the facility, obtain Plan of Correction documents, and secure signatures.
Findings
No immediate health or safety concerns were observed during the visit. The administrator received a copy of the report and licensee rights via email.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Administrator | Met with Licensing Program Analyst during the visit and received report and licensee rights. |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Oct 25, 2024
Visit Reason
An unannounced Case Management visit was conducted by Licensing Program Analyst Sabel Martinez to review facility operations and request staff training records.
Findings
The Licensing Program Analyst toured the facility, secured report signatures, delivered amended reports, and conducted an exit interview with the Administrator. No deficiencies or violations were explicitly stated in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Administrator | Administrator who assisted the Licensing Program Analyst during the visit and participated in the exit interview. |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Oct 4, 2024
Visit Reason
An unannounced Case Management visit was conducted in response to a previously substantiated complaint alleging neglect resulting in a resident sustaining a stage 4 pressure injury.
Findings
During the visit, an immediate $500 civil penalty was assessed related to the substantiated complaint of neglect. The civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.
Complaint Details
The complaint (Complaint # 08-AS-20190809110049) was substantiated on September 30, 2020, regarding neglect causing a stage 4 pressure injury to a resident.
Deficiencies (1)
| Description |
|---|
| Neglect resulting in a resident sustaining a stage 4 pressure injury |
Report Facts
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Licensee / Administrator | Met with during the visit and involved in exit interview |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 1
Oct 4, 2024
Visit Reason
An unannounced Case Management visit was conducted to assess compliance and address a previously substantiated complaint allegation regarding resident care.
Findings
During the visit, an immediate $500 civil penalty was assessed related to a previously substantiated complaint about a resident being left in soiled clothing. The deficiency was amended from a Type B to a Type A deficiency.
Complaint Details
The visit was in response to a substantiated complaint (Complaint # 08-AS-20191231162534) reported on December 31, 2019, and substantiated on June 18, 2021, regarding staff leaving a resident in soiled clothing.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident left in soiled clothing | Type A |
Report Facts
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Administrator | Met with during the visit and involved in exit interview |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Oct 4, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to a previously substantiated complaint regarding lack of supervision of a resident.
Findings
During the visit, an immediate $500 civil penalty was assessed related to the substantiated complaint. The deficiency was amended from a Type B to a Type A deficiency.
Complaint Details
Complaint # 08-AS-20220912085344 was substantiated on October 12, 2023, regarding lack of supervision of a resident.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Lack of supervision of a resident | Type A |
Report Facts
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Administrator | Met with during the inspection and involved in exit interview |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Oct 4, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements for the Point Loma Elder Care Facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and supplies were present and in working order. Staff and client records contained the required documents.
Report Facts
Licensed capacity: 6
Current census: 6
Hospice waiver capacity: 3
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Licensee and Administrator | Assisted Licensing Program Analyst during inspection and exit interview |
| Travonna Washington | Administrator | Assisted Licensing Program Analyst during inspection |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Nov 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not treat a resident with dignity, physically assaulted a resident resulting in injuries, and destroyed the resident's personal belongings.
Findings
The investigation substantiated that a former employee did not treat a resident with dignity, citing a physical confrontation with the resident. However, allegations that staff assaulted the resident causing injuries and destroyed personal belongings were unsubstantiated due to conflicting statements and lack of corroboration.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not treat a resident with dignity. The allegation that staff physically assaulted the resident resulting in injuries and destroyed personal belongings was unsubstantiated due to insufficient evidence and conflicting statements.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights - To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature was not met. | Type B |
Report Facts
Capacity: 6
Census: 6
Deficiency count: 1
Plan of Correction Due Date: Nov 15, 2023
Plan of Correction Completion Date: Dec 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Gaurav Rathi | Administrator | Facility administrator involved in exit interview and report receipt |
| Hugo Duran | Caregiver | Facility staff member met during the unannounced visit |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Oct 20, 2023
Visit Reason
An unannounced Required Annual Inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be organized, clean, and in good repair with no safety hazards observed. All required furnishings, equipment, and supplies were present and properly maintained. No residents were bedridden or receiving hospice care, and no deficiencies or violations were noted.
Report Facts
Non-ambulatory residents present: 5
Hospice waiver approved residents: 3
Bedridden residents allowed: 1
Days of perishable food present: 2
Days of non-perishable food present: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the inspection and authored the report |
| Gaurav Rathi | Administrator | Facility administrator who met with the Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Oct 12, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following a complaint received on 2022-09-12 alleging neglect and lack of supervision of a resident.
Findings
The investigation substantiated that facility staff failed to provide required assistance to one resident, resulting in a fall and minor injuries. The staff member omitted pertinent facts in the incident report, and immediate corrective action was taken by the administrator.
Complaint Details
The complaint alleged neglect/lack of supervision of a resident who fell and sustained minor injuries. The allegation was substantiated based on interviews, observations, and records review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not provide required assistance to 1 out of 6 residents, posing a potential safety risk. | Type A |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Nov 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Rathi | Administrator | Administrator involved in the investigation and exit interview |
| Riza Gloria Alvarez | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Mar 30, 2023
Visit Reason
The Licensing Program Analyst conducted a visit to deliver findings for an investigation and to conduct a case management visit.
Findings
No deficiencies were cited during the visit. Technical advisories were provided to the Co-Administrator.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the visit and delivered findings. |
| Gaurav Rathi | Administrator | Named as facility administrator and Co-Administrator present during exit interview. |
| Travonna Washington | Facility Manager | Met with Licensing Program Analyst during the visit. |
| Niki Mundhada Rathi | Co-Administrator | Joined the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Mar 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not afford residents dignity, yelled at residents, and did not afford residents to be free from intimidation.
Findings
The investigation included interviews with staff, residents, and outside sources, as well as observations and records review. The allegations were found to be unsubstantiated due to insufficient evidence supporting claims of staff misconduct regarding dignity, yelling, or intimidation.
Complaint Details
The complaint alleged that staff did not afford residents dignity, yelled at residents, and intimidated residents. The investigation found no evidence to support these allegations, and they were deemed unsubstantiated.
Report Facts
Capacity: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rebecca Hedgecock | Licensing Program Manager | Oversaw the complaint investigation |
| Travonna Washington | Facility Manager/Co-Administrator | Met with Licensing Program Analyst during exit interview |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Mar 23, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that meals did not meet a resident's needs.
Findings
The investigation included interviews, record reviews, and a facility tour. It was found that the resident required a mechanical soft diet and assistance with all activities of daily living. The resident's medical condition declined and they were admitted to hospice care, where poor meal intake was noted. There was no evidence of denial of food or water, and the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that meals did not meet the resident's needs. The allegation was investigated and found unsubstantiated based on interviews and records review.
Report Facts
Facility capacity: 6
Census: 6
Complaint control number: 08-AS-20220309105309
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Travonna Washington | Administrator | Met with during the investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Oct 31, 2022
Visit Reason
An unannounced required 1-year visit was conducted to evaluate the facility's compliance with licensing requirements and infection control protocols.
Findings
No deficiencies were cited or observed during the inspection. The facility's infection control mitigation plan, including disinfection, testing surveillance, screening protocols, and use of personal protective equipment, was evaluated and found satisfactory.
Report Facts
Capacity: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Rathi | Administrator | Met with Licensing Program Analyst during inspection |
| Tiffany Holmes | Licensing Program Analyst | Conducted the unannounced required 1-year visit |
| Simon Jacob | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Aug 22, 2022
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff failed to follow the admission agreement and increased rent for Resident 1 improperly.
Findings
The investigation found that although the allegation may have occurred, there was insufficient evidence to substantiate the violation. The facility did not increase Resident 1's rent until over a year after the complaint was filed, and proper written notice was provided as required.
Complaint Details
The complaint alleged failure to follow the admission agreement and improper rent increase for Resident 1. The investigation determined the complaint to be unsubstantiated.
Report Facts
Resident rent amount: 5750
Resident rent amount: 6250
Complaint received date: Oct 19, 2020
Facility capacity: 6
Facility census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Joseph Buda | Caregiver | Met with Licensing Program Analyst during the investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Apr 21, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on a self-reported incident received by the Regional Office on 12/3/2021.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst observed residents and reviewed facility records.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Administrator | Administrator present during the visit and participated in the exit interview. |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Sep 14, 2021
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance with licensing requirements and COVID-19 mitigation protocols.
Findings
The Licensing Program Analyst conducted a tour and observed the clients in care, providing technical assistance on infection control. No deficiencies were cited or observed during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gaurav Rathi | Administrator | Administrator present during the visit and participated in the exit interview. |
| Joseph Taylor | Live-In Caregiver | Met with Licensing Program Analyst during the inspection. |
| Rebecca Ruiz | Licensing Program Analyst | Conducted the inspection and evaluation. |
Inspection Report
Census: 5
Capacity: 6
Deficiencies: 0
Jun 30, 2021
Visit Reason
A virtual case management visit was conducted via FaceTime to deliver an amended report to the facility administrator.
Findings
The Licensing Program Analyst informed the licensee of the reasons for the amended report and provided the updated report for their records. An exit interview was conducted via video-call.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the virtual case management visit and delivered the amended report. |
| Gaurav Rathi | Administrator | Facility administrator who participated in the visit and exit interview. |
| John Rante | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 3
Jun 18, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff left a resident in soiled clothing, failed to provide proper care, and that the resident's signal system was not operating.
Findings
The investigation substantiated the allegations that due to staffing shortages, residents, including Resident 1, did not receive adequate incontinence care during night shifts, and staff failed to ensure bed and chair alarms were operational, posing potential health and safety risks. The facility implemented schedule changes and policies to address these issues.
Complaint Details
The complaint investigation was substantiated based on evidence that staff left a resident in soiled clothing, failed to provide proper care, and did not maintain the resident's signal system. The preponderance of evidence standard was met, validating the allegations.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Managed Incontinence: Licensee failed to ensure incontinent residents were kept clean and dry due to staff shortages on night shift. | Type A |
| Care of Persons with Dementia: Facility did not have adequate direct care staff to support residents' needs, including awake night supervision for residents with dementia. | Type B |
| Personnel Requirements–General: Facility personnel were not sufficient in numbers and competent to provide necessary services, including checking bed and chair alarms. | Type B |
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Date: Jan 8, 2020
Plan of Correction Due Date: Jul 18, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Gaurav Rathi | Administrator | Facility administrator involved in the investigation and exit interview |
Loading inspection reports...
