374603449-6-30-2022-08-AS-LTEZ-CFW2VH-20220630174357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603449
Report Date: 06/30/2022
Date Signed: 06/30/2022 05:23:23 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-20200303144113

FACILITY NAME:	GATE MANOR III		FACILITY NUMBER:	374603449
ADMINISTRATOR:	MA NIZA AMBALADA		FACILITY TYPE:	740
ADDRESS:	13114 GATE DRIVE		TELEPHONE:	(844) 320-1497
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 6	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Ma Niza Ambalada, Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not meet resident's incontinent care needs.

Unskilled staff are performing glucose testing on resident.

Unskilled staff are administering injections.

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.

Community Care Licensing (CCL) has investigated the above listed complaint allegations. The investigation consisted of a review of facility records and interviews of 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) and Resident 2 (R2). It was alleged that R1 and R2 were repeatedly left soiled by facility staff who were refusing to change the residents. Interviews of R1 and other outside sources who visited the facility regularly did not reveal evidence to support the allegation.

It was also alleged that unskilled staff performed glucose testing and administered injections to R1.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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-20200303144113

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 III	FACILITY NUMBER: 374603449
	VISIT DATE: 06/30/2022

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

Interviews conducted and records reviewed revealed that R1 was prescribed insulin injections at the time of admission into the facility. At the time, based upon interviews, record review, and LPA’s observation, R1 was alert and oriented and able to perform his/her own testing and injection. As R1’s condition deteriorated and R1 progressed to admission into hospice care, insulin was discontinued and R1 was prescribed and received oral medication. The investigation did not yield evidence to conclude that, during the time in which R1 was prescribed insulin, facility staff who were not skilled to do so conducted R1’s glucose testing or administered insulin injections to the resident.

Based upon a lack of evidence to corroborate the allegations, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Ma Niza Ambalada, Administrator, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Administrator’s signature on this report acknowledges receipt of copies of the rights and report.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2