<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603449
Report Date: 05/27/2026
Date Signed: 05/27/2026 04:16:38 PM

Document Has Been Signed on 05/27/2026 04:16 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GATE MANOR IIIFACILITY NUMBER:
374603449
ADMINISTRATOR/
DIRECTOR:		MA NIZA AMBALADAFACILITY TYPE:
740
ADDRESS:13114 GATE DRIVETELEPHONE:
(844) 320-1497
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
05/27/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Administrator Maniza AmbaladaTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Angelica Boyles made an unannounced Case Management visit to the facility in order to review facility records. LPA was welcomed by and discussed the purpose of the visit with Administrator Maniza Ambalada.

LPA conducted a brief facility tour and reviewed staff and resident records. Staff records reviewed revealed that there were no personnel files for Staff #1 (S1). [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Records for Staff #2 (S2) did not include criminal record clearance. A review of the Guardian background check system revealed S2 had eligible background clearance, but was not associated to the facility. Additionally, Staff #3 (S3) did not have a Health Screening Report (LIC503) on file.

Three deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809 D pages) and a Civil Penalty was assessed for the total of $500 (refer to attached LIC 421BG). A Plan of Correction was jointly developed with the Administrator. An exit interview was conducted with Administrator Maniza Ambalada, to whom a copy of this report, the LIC 809 D, LIC 421BG, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Angelica Boyles
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 05/27/2026 04:16 PM - It Cannot Be Edited


Created By: Angelica Boyles On 05/27/2026 at 12:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GATE MANOR III
FACILITY NUMBER: 374603449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2026
Section Cited
CCR
87412(a)

1
2
3
4
5
6
7
87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to email LPA required personnel records for S1 by POC due date.
8
9
10
11
12
13
14
LPA record review and interview with Administrator revealed that there were no personnel records for S1.
This poses a potential health risk to persons in care.
8
9
10
11
12
13
14
Type B
06/26/2026
Section Cited
CCR87412(a)(11)

1
2
3
4
5
6
7
87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on...each employee. Each personnel record shall contain the following information: (11) A health screening...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to email LPA a copy of S3's Health Screening by POC due date.
8
9
10
11
12
13
14
LPA record review and interview with Administrator revealed that S3 did not have a health screening report on file.
This poses a potential health risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/27/2026 04:16 PM - It Cannot Be Edited


Created By: Angelica Boyles On 05/27/2026 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GATE MANOR III
FACILITY NUMBER: 374603449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2026
Section Cited
CCR
87355(e)(3)

1
2
3
4
5
6
7
87355 Criminal Record Clearance(e) All individuals subject to a criminal record review ...shall prior to working...: (3) Request a transfer of a criminal record clearance...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will have S2 associated to the facility on Guardian and submit proof to LPA by POC due date.
8
9
10
11
12
13
14
LPA record review and interview with Administrator revealed S2 was not associated to the facility prior to working.
This poses an immediate health and safety risk to all persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4