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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604169
Report Date: 08/01/2022
Date Signed: 08/01/2022 12:01:22 PM

Document Has Been Signed on 08/01/2022 12:01 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA AMBROSIAFACILITY NUMBER:
374604169
ADMINISTRATOR:NAGHIBI, ALIFACILITY TYPE:
740
ADDRESS:1537 BRIGHTON GLEN ROADTELEPHONE:
(760) 290-3444
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY: 6CENSUS: 6DATE:
08/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ali Naghibi, AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver, Angelina Martinez who was informed of the purpose of the visit. Angelina called Administrator, Ali Naghibi who arrived at the facility shortly after. At the time of visit there was 1 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility inside and out with Angelina and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towel) in all restrooms. LPA did not observe any pools or bodies of water within the premises. LPA was informed that no weapons or ammunition is maintained at the home. No annual fees due.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to Ali Naghibi.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
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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