Gate Manor III

Type of visit: Office

An office meeting was held in the San Diego Adult and Senior Care Regional office. The following people were present at the meeting: RM Jerry Romero, LPM Simon Jacob, LPM Lizzette Tellez, LPA Angelica Boyles, Chuck Thomas and Suolang “Julie” Quzchen. The purpose of this meeting was to gather information regarding the operations of of Gate Manor, Gate Manor II, and Gate Manor III. Translation services approved by the Department were used during this office meeting. This report was mailed to Licensee, as licensee left.the state’s words, verbatim · CDSS document, Jun 3, 2026

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, May 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Jun 26, 2026

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: 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.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Administrator agreed to email LPA required personnel records for S1 by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a)(11) · Plan of correction due date: Jun 26, 2026

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: 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.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Administrator agreed to email LPA a copy of S3's Health Screening by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jun 26, 2026

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: 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.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Administrator will have S2 associated to the facility on Guardian and submit proof to LPA by POC due date.

Type of visit: Case Management - Annual Continuation

LPA Correia, accompanied by Administrator Ambalada, conducted a tour of the facility. Resident records were reviewed and found to be complete and up to date. The facility’s ambient temperature and hot water temperatures at sinks accessible to residents in care were measured and found to be within regulatory compliance. The facility maintained an adequate supply of food, including a 2‑day supply of perishable items and a 7‑day supply of non‑perishable items, all properly labeled and stored. During the tour, LPA observed operational smoke detectors, carbon monoxide detectors, and a fire extinguisher with a current inspection tag. Required postings were properly displayed, and a functional landline telephone was present. Sharps, toxins, and medications were locked and inaccessible to residents in care. Medications were reviewed and found to be administered as ordered, with documentation complete and accurate. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Resident bedrooms contained the required furnishings. Resident showers were equipped with non‑skid flooring and grab bars and were in working order. Doors, windows, and screens were in good condition. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were available. acknowledges receipt of these documents. The facility includes an adequately sized common area and a shaded outdoor space for activities and visitation. No bodies of water were present on the premises.. Per Administrator Ambalada, there are no firearms or ammunition on the premises. Based on the inspection conducted today, no deficiencies were cited. An exit interview was conducted, and a copy of this report, along with Licensee Rights (LIC 9058, rev. 01/16), was provided to Administrator Ambalada. Their signature on this form acknowledges receipt of the documents.the state’s words, verbatim · CDSS document, Feb 27, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself to Administrator Ambalada of Gate Manor III, was granted entry, and explained the purpose of the visit. Gate Manor III is licensed to serve six (6) residents, all of whom may be non-ambulatory, four (4) may be receiving hospice services, and one (1) bedridden, During today’s visit, the current census was five (5) residents: three (3) receiving Hospice services, and two (2) non-ambulatory. The facility was operating within its licensed capacity and conditions. An overall inspection of the facility began today; however, due to time constraints, LPA was unable to complete the visit and will return at a later time to conduct the remaining portion of the inspection. No deficiencies were cited during today’s visit. This report was discussed with Administrator Ambalada. A copy of the report and Licensee Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of both the rights and this report.the state’s words, verbatim · CDSS document, Feb 25, 2026

Allegation investigated: Staff do not ensure that resident's dietary needs are met.

Licensing Program Analyst (LPA) Correia conducted an unannounced visit to commence and conclude a complaint investigation. LPA Correia was met by Administrator Ambalada, identified herself, and explained the purpose of the visit. During today’s visit LPA conducted staff, resident, and Outside Source interviews, a resident records review, and facility tour. On September 25, 2025, the Department received a complaint alleging that the Licensee was not providing Resident1 (R1) meals to meet their diabetic dietary needs, indicating the facility served mostly starchy food (i.e., white rice and white bread). A review of R1’s facility records revealed they were admitted to the facility on May 26, 2025, following the discharge of a Skilled Nursing Facility (SNF). Records also showed R1 was diagnosed with Diabetic Mellitus, Lumar Fusion, Dementia, HTN, Vertigo, BPH (Prostate), and Depression. Further review of records showed R1 required no special dietary needs. [Continued on LIC 9099C] Unsubstantiated [Continuation of LIC 9099] An interview with the facility Administrator revealed they offer options and/or substitutes when requested by residents in care, and at times will make special trips to Sprouts for R1. An interview conducted with Resident 2 (R2) revealed they had lived at the facility for approximately 9 months, and stated staff were very accommodating. R2 also disclosed they were diabetic as well and felt the meals were healthy. R2 disclosed the facility had a variety of food. An additional interview was conducted with Outside Source 1 (OS1) who revealed no complaints regarding the facility's care or food/meals offered at the facility. OS1 disclosed R1 tends to find things to complain about and did not agree with the allegation. LPA, accompanied by the facility Administrator, conducted a tour of the facility kitchen. LPA observed a variety of wheat bread, brown rice, and other non-starchy foods. The Administrator also showed LPA two (2) boxes of Raisin Bran that R1 requests for breakfast each morning. Based on interviews, record reviews, and facility tour, the above listed allegation was determined Unsubstantiated. This finding means the preponderance of evidence standard was not met. An exit interview was conducted with Administrator Ambalada and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of the visit. Signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 08-AS-20250925160917

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA D. Roman was greeted and allowed entry into the facility by facility Director, Ma Niza Ambalada, to whom LPA discussed the purpose of today's visit. The facility’s license identifies that the facility has a maximum capacity of 6 elderly residents. During today’s inspection, 4 were at the facility. 2 bedrooms are empty. LPA D. Roman along with the Director, Ma Niza Ambalada toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and one bathroom was undergoing maintenance repairs. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable. LPA D. Roman observed about 2 to 3 days of perishable food, and at least 7 days non-perishable food present, all safely stored, expiration dates were randomly checked. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. LPA inquired if firearms were stored in the facility to which Director Ma Niza Ambalada, reported no. At 1:20PM, smoke alarms, carbon monoxide detectors were tested, emergency lighting, and facility telephone were all working. Most fire extinguishers have been replaced. However, the facility continued to have fire extinguishers present that were serviced in 2023. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff present. LPA reviewed staff and client records/files. Files reviewed contained required documents. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Director, Ma Niza Ambalada to whom copies of this report and the Licensee/Appeal Rights were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 6, 2025

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Ma.Niza Ambalada, Administrator to whom LPA discussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of six (6) elderly residents. During today’s inspection, six (6) were at the facility. LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No pools or bodies of water on the premises. Per Ma.Niza Ambalada, Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher has been serviced. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff present. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Ma.Niza Ambalada, Administrator to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 23, 2024