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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604169
Report Date: 11/18/2022
Date Signed: 11/18/2022 12:07:18 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2022 and conducted by Evaluator Chinwe Nwogene
COMPLAINT CONTROL NUMBER: 18-AS-20221115090047
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:
11/18/2022
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Ali Naghibi, AdministratorTIME COMPLETED:
09:54 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide resident representative with admissions agreement upon request.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On November 18, 2022, Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to investigate the above allegation. LPA met with Administrator, Ali Naghibi who was informed of the purpose of the visit. During the investigation, LPA interviewed Resident #1 (R1) Responsible Party, and interviewed Administrator.
Regarding the allegation “Facility staff did not provide resident representative with Admissions Agreement upon request”. LPA interviewed Administrator, Ali Naghibi who stated the Admission agreement was emailed to R1 Responsible Party when R1 moved in and was again emailed on November 15, 2022 when R1 Responsible Party reported to have not received the Admission Agreement. Administrator stated R1 Responsible Party confirmed receipt of the Admission Agreement on November 15, 2022. LPA called Resident #1 Responsible Party and was able to confirm Resident #1 Responsible Party received the Admission Agreement.
This agency has investigated the complaint alleging “Facility staff did not provide resident representative with admissions agreement upon request”. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted, and a copy of this report was reviewed with and provided to Ali Naghibi.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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