374604169-6-14-2021-08-AS-ETOS-C3Z2BZ-20210614171559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604169
Report Date: 06/14/2021
Date Signed: 06/14/2021 05:16:14 PM

Document Has Been Signed on 06/14/2021 05:16 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 AMBROSIA		FACILITY NUMBER:	374604169
ADMINISTRATOR:	NAGHIBI, ALI		FACILITY TYPE:	740
ADDRESS:	1537 BRIGHTON GLEN ROAD		TELEPHONE:	(714) 322-1910
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY: 6		CENSUS: 6	DATE:	06/14/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	04:50 PM
MET WITH:	Licensee, Ali Naghibi		TIME COMPLETED:	05:15 PM

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Licensing Program Manager (LPM) John Rante and Licensing Program Analyst (LPA) Eva Torres, conducted a Teleconference Office Visit with Licensee Ali Naghibi on today’s date. Today’s Office Visit is to discuss deficiencies that were cited at the facility on June 9, 2021, when amended reports were delivered to the Licensee. At the time of the visit on June 9, 2021, a joint Plan of Corrections (POCs) were not obtained from the Licensee. Today’s visit is to obtain the POCs for the deficiencies that were issued. The following deficiencies were cited in reference to Complaint Control Number: 08-AS-20191122121024.

Type A: Section: 87633(d) 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: Based on records reviewed and interviews conducted, the licensee did not ensure that the hospice care plans 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.

POC DUE DATE: 06/15/2021. The Licensee will submit confirmation of scheduled training by an outside source regarding hospice care plans by POC due date, 06/15/2021. Once training has been completed, the Licensee will submit the documents within 30 days.

Type B: 87465(a)(5): 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: 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.

POC DUE DATE: 07/14/2021. The Licensee will obtained outside source medication training for staff. The Licensee will submit proof of completed training by POC due date, 07/14/2021.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/14/2021

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Type B: 87625(b)(2): 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: 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.

POC Due Date: 07/14/2021. The Licensee will obtained incontinence training from an outside source for staff. The Licensee will submit proof of completed training by POC due date, 07/14/2021.

Type B: 87208(a): 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: 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.

POC Due Date: 07/14/2021. The Licensee will obtained training from an outside source regarding repositioning of bedridden residents for staff. The Licensee will submit proof of completed training by POC due date, 07/14/2021.

These deficiencies were cited in accordance to the California Code of Regulations, Title 22, Division 6, Chapter 8, and are previously noted on the reports delivered to the Licensee on June 9, 2021. An exit interview was conducted. The Licensee was provided a copy of his appeal rights (LIC9058 01/16), along with a copy of this report. An electronic read receipt will be requested as confirmation of receipt of documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

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