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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604169
Report Date: 06/09/2021
Date Signed: 06/09/2021 06:30:43 PM

Document Has Been Signed on 06/09/2021 06:30 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
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 - DeficienciesUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Administrator Ali Naghibi,TIME COMPLETED:
02:25 PM
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Licensing Program Manager (LPM) John Rante and Licensing Program Analyst (LPA) Eva Torres conducted a case management visit to cite violations discovered during an investigation.

On November 26, 2019, the Department conducted an on-site visit to investigate allegations of neglect. The investigation included a review of records and interviews conducted.

During the investigation, LPA reviewed the facility, hospice, and Resident #1's (R1) (See LIC 811- Confidential Names List for R1) records. According to R1's Physician's Report dated September 19, 2019, it noted R1 is bedridden, which means a person who requires assistance with turning or repositioning in bed. The report also indicated that R1 needed continuous bed care, a record of skin breakdown, and help with toileting, bathing, grooming, dressing, and medication management.

The facility's Plan of Operation under Care of Bedridden Residents was also reviewed. The plan stated that the facility would develop a plan to address the resident's needs, including the need to be repositioned every two hours and daily body checks for skin monitoring.

After reviewing the above records and conducted staff interviews, the licensee neglected to provide regular overnight care in adherence to the hospice care plan to include repositioning R1 every two hours and their incontinence needs due to R1's documented bedridden status.

Based on records reviewed and interviews conducted, a deficiency is cited per Title 22, Division 6 of the CA Code of Regulations on the attached LIC 809-D.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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Document Has Been Signed on 06/09/2021 06:30 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Evangelica Torres On 06/09/2021 at 02:14 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VILLA AMBROSIA
FACILITY NUMBER: 374604169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
06/30/2021
Section Cited
CCR
87208(a)

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Each facility shall have and maintain a current, written definitive plan of operation. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met as evidence by:
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Licensee is not willing to provide a plan of correction.
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Based on the review of the facility's Plan of Operation under Care of Bedridden Residents, the licensee did not follow their policy in meeting R1's needs of repositioning R1 every two hours. This posed an immediate health risk to one out 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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