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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001367
Report Date: 05/26/2022
Date Signed: 05/26/2022 05:05:53 PM


Document Has Been Signed on 05/26/2022 05:05 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:
05/26/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eric GilbertTIME COMPLETED:
05:25 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 Analysts (LPAs) Joseph Alejandre and Shobhana Frank made an unannounced visit to conduct a health and safety check at the facility. LPAs were greeted and granted entry by Administrator Eric Gilbert. Assistant Administrator Sue Anderson was also present. LPAs and Administrators toured the facility. The facility is a two story home with 9 bedrooms, 4 bathrooms, family room, dining room, living room and a 3 car garage. All residents reside on the first floor. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand. LPAs observed the kitchen is clean and organized. LPAs observed the resident bedrooms had the required furnishings. All resident beds had clean linens. LPA observed all bathrooms were operational. LPAs observed the facility had all utilities, water, gas, electricity and phone service. LPAs observed the air conditioning was on and cooling the facility. LPAs observed all residents were alert and interacted with the LPAs. LPAs toured the outside grounds. LPAs observed an empty koi pond that is fenced off and inaccessible to the residents in care. LPAs observed both exit gates are operational. The garage is used for storage and off limits to the residents. All smoke detectors/carbon monoxide detectors tested operational. LPAs did not observe any hazards in the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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 1