374603450-1-15-2025-08-AS-DRON-DCXVLF-20250115153151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603450
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:32:10 PM

Document Has Been Signed on 01/15/2025 03:32 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		FACILITY NUMBER:	374603450
ADMINISTRATOR/ DIRECTOR:	ROLANDO CORPUZ		FACILITY TYPE:	740
ADDRESS:	13110 GATE DRIVE		TELEPHONE:	(844) 320-1497
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY: 6		CENSUS: 5	DATE:	01/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Administrator, Ma Niza Ambalada		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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

Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator, Ma Niza Ambalada. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all may be non-ambulatory and one of which may be bedridden.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to client. Medications were labeled, as required, and stored in locked areas. Water temperature was measured at 120 degrees F.

No pools or bodies of water on the premises. Per Ma Niza Ambalada, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present. First aid kits were complete and readily accessible.

Resident records reviewed had required documentation. Staff records reviewed first aid certificates expired on 01/09/2024.

Two (2) deficiencies were cited today for expired CPR certificate and no Infection Control Plan.

An exit interview was conducted with Administrator, Ma Niza Ambalada, to whom a copy of this report and the Licensee/Appeal Rights, were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document is an Amendment of Original Document on 04/17/2025 01:50 PM

Created By: David Roman On 01/15/2025 at 02:34 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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	FACILITY NUMBER: 374603450
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	**DISREGARD PAGE LPA ERROR**
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	**DISREGARD PAGE LPA ERROR**

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	**DISREGARD PAGE LPA ERROR****DISREGARD PAGE LPA ERROR**
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	**DISREGARD PAGE LPA ERROR**

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lizzette Tellez

LICENSING EVALUATOR NAME:

David Roman

LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

Page: 7 of 9

Document is an Amendment of Original Document on 04/17/2025 02:01 PM

Created By: David Roman On 01/15/2025 at 02:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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	FACILITY NUMBER: 374603450
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	**DISREGARD PAGE LPA ERROR**
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	**DISREGARD PAGE LPA ERROR**

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	**DISREGARD PAGE LPA ERROR**
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	**DISREGARD PAGE LPA ERROR**

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lizzette Tellez

LICENSING EVALUATOR NAME:

David Roman

LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

Page: 8 of 9

Document Has Been Signed on 04/17/2025 01:43 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/17/2025 01:38 PM

Created By: David Roman On 01/15/2025 at 03:18 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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	FACILITY NUMBER: 374603450
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)

This requirement is not met as evidenced by: Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 1 records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	Licensee agreed to develop Infection Control Plan and provide proof to the Department by POC due date.

Type B

Section Cited

HSC

1569.618(c)(3)

This requirement is not met as evidenced by: Other Provisions (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid is on duty...at all times.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have staff complete CPR training by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lizzette Tellez

LICENSING EVALUATOR NAME:

David Roman

LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

Page: 9 of 9