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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603449
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:15:04 PM

Document Has Been Signed on 03/06/2025 03:15 PM - 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:GATE MANOR IIIFACILITY NUMBER:
374603449
ADMINISTRATOR/
DIRECTOR:
MA NIZA AMBALADAFACILITY TYPE:
740
ADDRESS:13114 GATE DRIVETELEPHONE:
(844) 320-1497
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Director,Ma Niza AmbaladaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA D. Roman was greeted and allowed entry into the facility by facility Director, Ma Niza Ambalada, to whom LPA discussed the purpose of today's visit. The facility’s license identifies that the facility has a maximum capacity of 6 elderly residents. During today’s inspection, 4 were at the facility. 2 bedrooms are empty.

LPA D. Roman along with the Director, Ma Niza Ambalada toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and one bathroom was undergoing maintenance repairs. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable.

LPA D. Roman observed about 2 to 3 days of perishable food, and at least 7 days non-perishable food present, all safely stored, expiration dates were randomly checked. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. LPA inquired if firearms were stored in the facility to which Director Ma Niza Ambalada, reported no. At 1:20PM, smoke alarms, carbon monoxide detectors were tested, emergency lighting, and facility telephone were all working. Most fire extinguishers have been replaced. However, the facility continued to have fire extinguishers present that were serviced in 2023. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff present. LPA reviewed staff and client records/files. Files reviewed contained required documents. No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Director, Ma Niza Ambalada to whom copies of this report and the Licensee/Appeal Rights were provided at the conclusion of the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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