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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604169
Report Date: 06/09/2021
Date Signed: 06/10/2021 09:24:00 AM

Document Has Been Signed on 06/10/2021 09:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
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:
06/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Ali Naghibi,TIME COMPLETED:
02:45 PM
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Licensing Program Manger (LPM) John Rante and Analyst (LPA) Eva Torres conducted a case management visit to amend two reports that were created on 11/26/2019 and 04/29/20. LPA Torres met with Mr. Naghibi, informed him of the purpose of the visit. During the visit, LPA attempted to obtain his signature on the amended reports. 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.
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.

LIC809 (FAS) - (06/04)
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