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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603449
Report Date: 10/03/2025
Date Signed: 10/03/2025 04:01:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/25/2025 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20250925160917
FACILITY NAME:GATE MANOR IIIFACILITY NUMBER:
374603449
ADMINISTRATOR:MA NIZA AMBALADAFACILITY TYPE:
740
ADDRESS:13114 GATE DRIVETELEPHONE:
(844) 320-1497
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Manzia AmbaldaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not ensure that resident's dietary needs are met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Correia conducted an unannounced visit to commence and conclude a complaint investigation. LPA Correia was met by Administrator Ambalada, identified herself, and explained the purpose of the visit.

During today’s visit LPA conducted staff, resident, and Outside Source interviews, a resident records review, and facility tour.

On September 25, 2025, the Department received a complaint alleging that the Licensee was not providing Resident1 (R1) meals to meet their diabetic dietary needs, indicating the facility served mostly starchy food (i.e., white rice and white bread). A review of R1’s facility records revealed they were admitted to the facility on May 26, 2025, following the discharge of a Skilled Nursing Facility (SNF). Records also showed R1 was diagnosed with Diabetic Mellitus, Lumar Fusion, Dementia, HTN, Vertigo, BPH (Prostate), and Depression. Further review of records showed R1 required no special dietary needs.

[Continued on LIC 9099C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
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-20250925160917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GATE MANOR III
FACILITY NUMBER: 374603449
VISIT DATE: 10/03/2025
NARRATIVE
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[Continuation of LIC 9099]

An interview with the facility Administrator revealed they offer options and/or substitutes when requested by residents in care, and at times will make special trips to Sprouts for R1. An interview conducted with Resident 2 (R2) revealed they had lived at the facility for approximately 9 months, and stated staff were very accommodating. R2 also disclosed they were diabetic as well and felt the meals were healthy. R2 disclosed the facility had a variety of food. An additional interview was conducted with Outside Source 1 (OS1) who revealed no complaints regarding the facility's care or food/meals offered at the facility. OS1 disclosed R1 tends to find things to complain about and did not agree with the allegation.

LPA, accompanied by the facility Administrator, conducted a tour of the facility kitchen. LPA observed a variety of wheat bread, brown rice, and other non-starchy foods. The Administrator also showed LPA two (2) boxes of Raisin Bran that R1 requests for breakfast each morning.

Based on interviews, record reviews, and facility tour, the above listed allegation was determined Unsubstantiated. This finding means the preponderance of evidence standard was not met.

An exit interview was conducted with Administrator Ambalada and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of the visit. Signature below confirms receipt of the reports.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2