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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 12:04:06 PM

Substantiated


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
08/10/2022 and conducted by Evaluator Chinwe Nwogene
COMPLAINT CONTROL NUMBER: 18-AS-20220810150404
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:
09:55 AM
MET WITH:Ali Naghibi, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility did not provide a refund.
Facility did not allow resident to have visitors.
INVESTIGATION FINDINGS:
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On November 18, 2022, Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to conclude the complaint investigation into the allegation listed above. 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, interviewed staff, Interviewed Hospice Social Worker, Interviewed Hospice Nurse, and reviewed resident file.
Regarding the allegation “Facility did not provide a refund”. It was alleged facility did not provide refund to R1 Responsible party after R1 passed away. Interview with R1 Responsible party revealed R1 Responsible party was unaware of the facility refund polices and didn't receive a written notice from facility regarding contract termination and refund upon R1 death. LPA interviewed Administrator, Ali Naghibi who stated R1 belongings was still in the facility after R1 Passed away and the notice for refund and contract termination is already in R1 admission agreement. LPA reviewed R1 Admission Agreement Page 8, under Death of a Resident. Admission agreement stated “The licensee shall, within 3 days of becoming aware of a resident’s death, provide written notice to specified persons of the facility’s policies regarding contract termination at death and refunds” which facility failed to abide to.

Continue on LIC9099C
Substantiated
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)
Page: 1 of 3
Control Number 18-AS-20220810150404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 AMBROSIA
FACILITY NUMBER: 374604169
VISIT DATE: 11/18/2022
NARRATIVE
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Continued From LIC9099

Regarding the allegation “Facility did not allow resident to have visitors”. It was alleged facility didn’t allow R1 receive visitors. LPA interviewed staff and Administrator who denied refusing resident to have visitors. Interview with Hospice Nurse revealed, Hospice Nurse was allowed to visit R1. However, Interview with Hospice Social Worker revealed, Hospice Social Worker request to visit R1 was denied by the Administrator, Ali Naghibi. Proof of the denial via text message was provided to LPA.

Based on LPA interviews and Resident File Review the preponderance of evidence standard has been met. Therefore, the above allegation(s) are found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6) are being cited on the attached LIC 9099D). An exit interview was conducted, and a copy of this report was reviewed and provided along with appeal rights to Ali Naghibi.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220810150404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 AMBROSIA
FACILITY NUMBER: 374604169
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited
HSC
1569.652(d)
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Termination of admission agreement upon death of resident;
(d) If fees are assessed while a resident’s personal property remains in a unit after the resident is deceased, a licensee shall, within three days of becoming aware of the resident’s death, provide to the resident’s responsible person, or other individual or individuals as identified in the admission agreement or attachment, written notice of the facility’s policies regarding contract termination upon death and refunds.
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Licensee stated a refund will be issued to R1 Responsible Party and proof of the refund will be provided to LPA by POC due date 11/28/2022.
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This requirement is not met based as evidence by interview and file review. The licensee did not comply with the section cited above by not providing to R1 Responsible Party a written notice of the facility’s policies regarding contract termination upon death and refunds which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
11/28/2022
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice,...
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Administrator, Ali Naghibi stated a written statemnt of understanding of the regulation cited will be provided to LPA by the POC due date 11/28/2022.
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This requirement is not met based as evidence by interview and file review. The licensee did not comply with the section cited above by not allowing the R1 Hospice Social Worker visit R1 which poses an immediate health, safety or personal rights risk to persons 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3