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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001367
Report Date: 03/30/2022
Date Signed: 03/30/2022 12:45:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/30/2022 12:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GENTLE CARE HOMEFACILITY NUMBER:
306001367
ADMINISTRATOR:EMERITA GARROVILLASFACILITY TYPE:
740
ADDRESS:416 S. JENNIFER LANETELEPHONE:
(714) 289-1260
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 4DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Emerita Garrovillas, Licensee and Eric Gilbert, AdministratorTIME COMPLETED:
12:59 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required/ annual inspection visit. LPA Quiroz was greeted and granted entry into the facility by Administrator Eric Gilbert and explained the reason for the visit. On or about 10:40am, Licensee Emerita Garrovillas arrived to the facility.
On or about 10:20am, LPA Rosie Quiroz along with Administrator Eric Gilbert, Staff 1 (S1) and Staff 4 (S4) toured the facility. LPA Rosie Quiroz observed 4 residents in care during today's visit. LPA Rosie Quiroz observed 1 of 4 residents relaxing in their bedroom and 3 of 4 residents in the living room area relaxing and interacting with staff.
All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. All rooms are single occupancy. Upon arrival to the facility, LPA Rosie Quiroz was not properly screened for COVID-19. (S1) indicated "No, we are not screening anyone who is coming in the door." LPA Rosie Quiroz did not observe a sanitizing station in the facility during today's visit. Licensee Emerita Garrovillas indicated "I don't know what happened to it, they removed it." Facility utilizes a visitor sign in sheet and not recording visitor's COVID-19 screening. (S1) indicated "Not taking residents temperatures daily and not documenting results since 2/25/2022." LPA Rosie Quiroz observed ample sanitizer spread out throughout the facility. Facility has two COVID-19 precaution postings throughout the facility. Licensee Emerita Garrovillas indicated "I will put up more COVID-19 postings up." Facility mitigation plan has been submitted on 7/2/2021 and pending approval. LPA Rosie Quiroz observed an ample supply of emergency food and water in the garage area. LPA Rosie Quiroz toured the outside grounds and observed tables and chairs with shaded area in backyard area.
At 10:35 am, LPA Rosie Quiroz observed knives in kitchen area to be unlocked/unsecured. (SEE LIC 809-D) Facility has a plan for COVID-19 testing residents and staff as needed as well as a plan for isolation and quarantine. LPA Quiroz reviewed four of four resident files during the visit and all contained updated emergency information. During today's visit, LPA Rosie Quiroz observed two of four residents have a current bedridden status in the file (SEE 412IM). Licensee Garrovillas indicated all residents and staff are vaccinated for COVID-19.CONTINUED NEXT PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2022 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GENTLE CARE HOME
FACILITY NUMBER: 306001367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2022
Section Cited

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Care of Bedridden Residents-87606(c):
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).Based on record review, the licensee did...CONTINUE
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CONTINUE...not comply with the section cited above. LPA observed R1 and R2 having bedridden status deemed indefinite per physician reports dated 1/29/22 and 2/2/22. Facility does not have bedridden fire clearance. This poses an immediate health and safety risk to persons in care.
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CIVIL PENALTY ASSESSED.
Type A
03/31/2022
Section Cited

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CARE OF PERSONS WITH DEMENTIA-87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Based on record review and observation, at 10:35am, LPA observed unlocked/unsecured knives in kitchen area. During today's visit, S1 locked and secured kitchen knives in locked and secured area in medication cabinet in dining room area.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GENTLE CARE HOME
FACILITY NUMBER: 306001367
VISIT DATE: 03/30/2022
NARRATIVE
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 LPA Rosie Quiroz consulted with Licensee Emerita Garrovillas regarding the importance of following department recommended guidelines for covid precautions and visitation for residents.
Based on observations made during today's visit, the following deficiencies were cited based on Title 22,
Division 6, of the California Code of Regulations. An exit interview to review this report was conducted with Licensee Emerita Garrovillas, and a copy along with Appeal Rights, LIC 811- Confidential Names list, LIC 809-D, LIC 421C- Civil Penalty Assessment, and LIC 9102TV- Advisory Notes were provided via email.

***CIVIL PENALTY ASSESSED DURING TODAY'S VISIT***
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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