374603450-10-2-2023-08-AS-SJAB-D3RKRV-20240327080831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603450
Report Date: 10/02/2023
Date Signed: 10/02/2023 02:21:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2023 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20230922150951

FACILITY NAME:	GATE MANOR		FACILITY NUMBER:	374603450
ADMINISTRATOR:	RIVERA, VON ALLANNE		FACILITY TYPE:	740
ADDRESS:	13110 GATE DRIVE		TELEPHONE:	(844) 320-1497
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 6	DATE:	10/02/2023
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Administrator Maniza Ambalada		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair
Staff did not keep the facility free from cockroaches

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Amy Rodgers and Licensig Program Manders (LPM) Denise Powell made an unannounced visit to the facility to conduct a Complaint Visit . LPA Rodgers and LPM Powell were met by Maniza Ambalada, Administrator, and were granted entry into facility. LPA met with Ms. Ambalanda and discussed the purpose of the visit.

At 11:05 am LPA and LPM toured facility and interviewed staff. LPA inspected the kitchen cabinets and drawers inclusing food pantry areas. LPA observed dead cockroaches and one live cockroach, however record reviews confirm facility has ongoing pest control services and has added interior roach control. Facility interior appeared clean and in overall good condition. LPA and LPM inspected water leak area located inside the staff office. Repairs were made timely and no evidence of current leak, dry rott, or mildew was observed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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 2

Control Number 08-AS-20230922150951

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GATE MANOR	FACILITY NUMBER: 374603450
	VISIT DATE: 10/02/2023

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
26
27
28
29
30
31
32

continued 9099

Based on observations and record reviews there is insufficient evidence to support the allegations.

The allegations are determined as unsubstantiated meaning they could have happened or be true, there is not a preponderance of evidence to meet the standard. An exit interview was conducted with Maniza Ambalada, Administrator, and a copy of this report along with the licensee rights was provided.

Administrator signature confirms receipt of these rights.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2