Villa Ambrosia

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Aug 31, 2023

Allegation investigated: Facility staff did not provide resident representative with admissions agreement upon request.

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. Unfoundedthe state’s words, verbatim · CDSS document, Nov 18, 2022 · control 18-AS-20221115090047

Allegation investigated: Facility did not provide a refund. Facility did not allow resident to have visitors.

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 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.the state’s words, verbatim · CDSS document, Nov 18, 2022 · control 18-AS-20220810150404

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(d) · Plan of correction due date: Nov 28, 2022

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. 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.the state’s words, verbatim · CDSS document, Nov 18, 2022

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Nov 28, 2022

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,... 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.the state’s words, verbatim · CDSS document, Nov 18, 2022

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver, Angelina Martinez who was informed of the purpose of the visit. Angelina called Administrator, Ali Naghibi who arrived at the facility shortly after. At the time of visit there was 1 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility inside and out with Angelina and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towel) in all restrooms. LPA did not observe any pools or bodies of water within the premises. LPA was informed that no weapons or ammunition is maintained at the home. No annual fees due. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Ali Naghibi.the state’s words, verbatim · CDSS document, Aug 1, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced annual required licensing inspection. LPA was granted entry by Caregiver Angie Martinez. LPA was granted entry after identifying themselves and disclosing the purpose of their visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Administrator Ali Naghibi including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Plans for Infection Control and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and face coverings recommended to residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. . No deficiencies were observed during today's visit. An exit interview was conducted with Administrator Ali Naghibi and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) was provided to them via email; an email read receipt confirms receipt of this report and these rightsthe state’s words, verbatim · CDSS document, Aug 24, 2021