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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603448
Report Date: 03/30/2022
Date Signed: 03/30/2022 04:45:34 PM

Unsubstantiated


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
03/03/2020 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20200303141732
FACILITY NAME:GATE MANOR IIFACILITY NUMBER:
374603448
ADMINISTRATOR:MANIZA AMBALADAFACILITY TYPE:
740
ADDRESS:13106 GATE DRIVETELEPHONE:
(844) 320-1497
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Anafe Rivera, Site ManagerTIME COMPLETED:
02:02 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not meet resident's incontinent care needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Ma Niza Ambalada, Administrator, to whom LPA disclosed the reason for the visit. Anafe Rivera, Site Manager, was called and arrived a short time later.

Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of a tour of the facility, review of facility records, and interviews with staff and outside sources.

It was reported to Community Care Licensing that facility staff were not meeting the incontinent care needs of Resident 1 (R1) [an LIC 811 Confidential Names List was provided to staff to identify the resident]. It was alleged that R1 was repeatedly left soiled by facility staff who were refusing to change the resident. Interviews and a review of records generated by outside sources did not provide sufficient evidence to support the allegation.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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 2
Control Number 08-AS-20200303141732
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: GATE MANOR II
FACILITY NUMBER: 374603448
VISIT DATE: 03/30/2022
NARRATIVE
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Based upon a lack of evidence to conclude that facility staff were not meeting the resident’s incontinent care needs, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Anafe Rivera, Site Manager, and a copy of this report and Licensee/Appeal Rights (LIC 9058) will be provided, via email, to the Site Manager following the visit. An electronic read receipt confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2