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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604169
Report Date: 04/29/2020
Date Signed: 06/09/2021 06:34:47 PM

Substantiated


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
11/22/2019 and conducted by Evaluator Evangelica Torres
COMPLAINT CONTROL NUMBER: 08-AS-20191122121024
FACILITY NAME:VILLA AMBROSIAFACILITY NUMBER:
374604169
ADMINISTRATOR:NAGHIBI, ALIFACILITY TYPE:
740
ADDRESS:1537 BRIGHTON GLEN ROADTELEPHONE:
(714) 322-1910
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:6CENSUS: 6DATE:
04/29/2020
UNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Administrator Ali Naghibi,TIME COMPLETED:
02:29 PM
ALLEGATION(S):
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Licensee failed to follow resident's hospice care plan.
Licensee failed to administer Resident #1’s medication as prescribed.
Licensee failed to meet resident's incontinence needs.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) John Rante and Licensing Program Analyst (LPA) Eva Torres conducted a visit to deliver findings on the above allegations. LPA identified herself, spoke with Administrator Ali Naghibi, and disclosed the purpose of the visit. The investigation included a review of facility and outside source's records, as well as conducted interviews.

It was alleged the facility did not follow Resident #1’s (R1) (See LIC 811- Confidential Names List for R1) hospice care plan. It was further alleged that the facility neglected to meet R1's incontinent needs and failed to administer R1's medication as prescribed.

On September 20, 2019, R1 was admitted to the licensed facility with hospice services for stage IV pressure injuries. On the same day, hospice staff documented that they informed the facility staff of the seriousness of the pressure injuries and that R1 required to be repositioned every two hours, as well as incontinence care. Additionally, the hospice admission records dated September 19, 2019, showed that R1 was prescribed a Hoyer lift and a call alert button to be in proximity of R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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 5
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20191122121024
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: VILLA AMBROSIA
FACILITY NUMBER: 374604169
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
06/10/2021
Section Cited
CCR
87633(d)
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Hospice Care of Terminally Ill Residents: The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement was not met as evidenced by:
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Licensee is not willing to provide a plan of correction.
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Based on records reviewed and interviews conducted, the licensee did not ensure that the hospice care plan matched the services actually being provided by facility staff to meet R1’s care needs at all times. This posed an immediate health risk to one of five residents in care.
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Under Appeal
Type B
06/30/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical ….and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:
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Licensee is not willing to provide a plan of correction.
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Based on records reviewed and interviews conducted, the licensee did not assist R1 with their routine medication as prescribed. This posed a potential health risk to one of five residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20191122121024
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: VILLA AMBROSIA
FACILITY NUMBER: 374604169
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
06/30/2021
Section Cited
CCR
87625(b)(2)
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 Managed Incontinence:..the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by
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Licensee is not willing to provide a plan of correction.
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Based on records reviewed and interviews conducted, the licensee did not ensure that R1, who was incontinent, was provided routine incontinent care during the night. This posed a potential health risk to one out five residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20191122121024
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: VILLA AMBROSIA
FACILITY NUMBER: 374604169
VISIT DATE: 04/29/2020
NARRATIVE
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Moreover, a review of the hospice assessment dated September 22, 2019, revealed that R1 required care in bathing, grooming, dressing, hygiene, transferring, toileting, and medication management. Physician’s Report dated September 19, 2019, notes R1 as bedridden, which means a person who requires assistance with turning or repositioning in bed. The report indicated that R1 required continuous bed care, a record of skin breakdown, and assistance with toileting, bathing, grooming, dressing, and medication management. The facility's pre-assessment, dated September 20, 2019, showed that the facility was aware that R1 required assistance with repositioning, as the assessment showed that R1 would be assisted with bathing, grooming, hygiene, toileting, transferring with a Hoyer lift, repositioning, and medication management. In further support, on October 7, 2019, hospice documented that they held a case conference with the licensee to discuss R1’s care needs, to include informing the licensee of the importance of repositioning R1 every two hours. Also, hospice nursing notes dated October 12, 2019, revealed that R1 was found soiled in their clothes with a large amount of bowl movement.
Although the pre-assessment appraisal and supporting documentation such as the Physician’s Report and hospice plan all confirmed R1 required repositioning every two hours and incontinence care, on October 17, 2019, the licensee updated R1's assessment, in which the plan confirmed that the facility would not provide overnight care from 08:00 PM to 08:00 AM. Investigation revealed the R1’s responsible party did not agree with the new assessment as it did not meet the resident’s needs and it noted that R1 was non-ambulatory; although, the physician had deemed R1 as bedridden.
Hospice staff were interviewed by the LPA and their interviews revealed that on multiple occasions, upon hospice arrival to the facility to perform hospice services, they found R1 soiled in their bowel movement. In addition, hospice interviews also noted that R1 disclosed to them that their needs were not being met by the licensee, as R1 stated that they were screaming for help during the night. An interview with the hospice staff confirmed that on November 11, 2019, they spoke with R1’s responsible party about possible new placement to another licensed facility.
Though staff interviews were inconsistent, their interviews confirmed that incontinence care and repositioning was not being provided during the night due to the facility’s employment policy of no wake staff between 10:00 PM to 06:00 AM.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20191122121024
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: VILLA AMBROSIA
FACILITY NUMBER: 374604169
VISIT DATE: 04/29/2020
NARRATIVE
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Furthermore, a review of hospice nursing notes dated November 08, 2019, showed that hospice staff held a secondary meeting with the licensee. During the meeting, the licensee demanded that hospice provide an overnight nurse as a result of R1 screaming at night to be repositioned. The nursing notes also documented that the hospice medical professional was “unable to reason with owner” (licensee) to meet R1’s needs. Therefore, the hospice agency medical professional notified R1’s responsible party of the outcome of the meeting, in which the responsible party expressed interest in relocating R1 to another licensed Residential Care Facility for Elderly (RCFE) that can meet the needs of R1. On November 16, 2019, R1 was relocated to another licensed RCFE that can meet R1’s needs.
In reviewing the facility's Plan of Operation under Care of Bedridden Residents, the plan stated that the facility would develop a plan to address resident's needs, including the need to be repositioned every two hours and daily body checks for skin monitoring.
Moreover, facility staff, outside sources, and R1's interviews confirmed that the facility neglected to provide regular overnight care in adherence to the hospice care plan to include repositioning every two hours and R1's incontinence needs due to R1’s documented bedridden status.
On November 06, 2019, hospice documented that they prescribed a medication to be given routinely at night. Then, on November 09, 2019, hospice increased the medication dosage to assist R1 with any discomfort. LPA reviewed the facility's medication logs and compared them with the physician's orders. Based on the review of the medication's records, the facility did not administer the routine mediation from November 06, 2019, through November 09, 2019. Hospice records and interviews conducted supported that the medication was prescribed and discussed with the facility on November 01, 2019, November 06, 2019, and November 09, 2019. On November 10, 2019, the medication was discontinued.
Based on the Department's interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegations are SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6), deficiencies are cited on the attached LIC 9099D.
An exit interview was conducted with Administrator, Naghibi. The Licensee/Appeal Rights (LIC 9058 01/16) and a copy of this report was provided to Mr. Naghibi via email. A return email or reply receipt from the Mr. Naghibi will confirm receipt of documents. This report is an amended version of the original document that was created on April 29, 2020.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5