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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604169
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:36:59 PM

Document Has Been Signed on 08/31/2023 04:36 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
RIVERSIDE AC/SC, 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:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:ALI NAGHIBI, LICENSEETIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual inspection. LPA was greeted by Licensee Ali Naghibi and explained the purpose of the visit. A tour of the facility was conducted inside and out. At the time of visit, there were six (6) clients home and two (2) staff were available. LPA conducted staff and client interviews.

The facility is a seven (7) bedroom, four and a half (4.5) bathroom one story home. Clients occupy six (6) bedrooms and one (1) bedroom is reserved for staff. All clients have a private bedroom.

During the tour the following was observed: Clients bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible to clients. Hot water was tested at 107 degrees Fahrenheit. Backyard provides shade for clients and is free from obstructions.
Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional.
Care & Supervision: Facility has sufficient care staff employed.
Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted quarterly. The last drill was conducted on 6/30/2023.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA AMBROSIA
FACILITY NUMBER: 374604169
VISIT DATE: 08/31/2023
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Record Review and Client/Staff Files: LPA reviewed current staff records and all staff have Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Client records were reviewed and contained required documents including Admissions Agreements, Care Appraisal Plans and current Physician reports.
Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Licensee, Ali Naghibi.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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