374603450-6-30-2022-08-AS-LTEZ-CFW2LU-20220630173006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603450
Report Date: 06/30/2022
Date Signed: 06/30/2022 04:33:45 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-20200303135217

FACILITY NAME:	GATE MANOR		FACILITY NUMBER:	374603450
ADMINISTRATOR:	CARMELA B WALKER		FACILITY TYPE:	740
ADDRESS:	13110 GATE DRIVE		TELEPHONE:	(844) 320-1497
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 6	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	03:06 PM
MET WITH:	Ma Niza Ambulada, Staff		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

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Licensee is not meeting resident's incontinent care needs.

Licensee interfered with resident’s right to select their own hospice agency.

INVESTIGATION FINDINGS:

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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, Staff, 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). It was alleged that R1 was repeatedly left soiled by facility staff. Records reviewed during the investigation and interviews conducted with outside sources who visited the facility regularly did not yield evidence to corroborate the allegation.

It was also alleged that the licensee interfered with R1’s right to select his/her own hospice agency. It was

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)

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Control Number 08-AS-20200303135217

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	FACILITY NUMBER: 374603450
	VISIT DATE: 06/30/2022

NARRATIVE

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determined during investigative interview that R1 previously received services from a hospice agency, but services that were being provided to R1 by the hospice agency were being discontinued, as R1 was not eligible to receive additional services from the agency. R1’s responsible party was presented the opportunity to select a different hospice agency, which the responsible party did. R1’s responsible party confirmed that the decision was made by him/her, and the licensee did not make the selection or force the selection of any particular hospice agency.

Based upon a lack of sufficient evidence to conclude that either of the allegations occurred, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, evidence was not obtained to prove that the alleged violations occurred.

An exit interview was conducted with Ma Niza Ambalada, Staff, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the staff at the conclusion of the visit. Ma Niza Ambalada’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)

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