306001367-5-27-2022-22-AS-AMEL-CETUQ3-20220527154630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001367
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:47:07 PM

Document Has Been Signed on 05/27/2022 03:47 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 HOME		FACILITY NUMBER:	306001367
ADMINISTRATOR:	EMERITA GARROVILLAS		FACILITY TYPE:	740
ADDRESS:	416 S. JENNIFER LANE		TELEPHONE:	(714) 289-1260
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS:	DATE:	05/27/2022
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee Emerita Garrovillas and Perspective Licensee Eric Gilbert		TIME COMPLETED:	12:00 PM

NARRATIVE

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On today's date, Regional Manager (RM) Marina Stanic, Licensing Program Managers (LPMs) Alisa Ortiz, and Armando Lucero and Licensing Program Analysts (LPAs) Andrea Mendivil and Joseph Alejandre met virtually with Licensee Emerita Garrovillas on this day for the purpose of discussing potential facility closure. Also present virtually was applicant Eric Gilbert.

During the meeting all participants were reminded of prior meeting held on 01/18/2022 and the expectations as agreed upon regarding the pending change of ownership application submitted by Mr. Gilbert. Following the meeting the Department has been contacted by Licensee and Applicant on multiple occasions regarding concerns over who has what type of authority over the facility.

The following was discussed:

· Licensee's responsibilities of facility oversight
· Licensee's requirement to maintain control of facility and property
· Licensee's responsibility to ensure all individuals are associated to the facility
· Licensee expressed concerns regarding working alongside Applicant
· Applicant expressed concerns regarding working alongside Licensee

(Continued..)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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 05/27/2022 03:47 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: 05/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/27/2022 Section Cited	1 2 3 4 5 6 7	87355 Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance...This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on file review Licensee failed to ensure that applicant and Ms. Anderson's criminal record clerance was transfered to the facility. This poses an immediate threat to the health and safety to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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: 05/27/2022

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The following was agreed upon during today's meeting:
· Licensee has decided to designate Applicant as Facility Administrator and act on her behalf at her direction for the day to day operations of the facility.
· Applicant has agreed to act as facility administrator on behalf of the licensee under her directions for the day to day operations of the facility.
· Both parties agreed to work together amicably and respectfully for the duration of the change of ownership application process in order to ensure the health and safety of the residents in care.
· RM Stanic reminded both parties that any individual making decision regarding operation of the facility must be employed by the Licensee. In addition, the Licensee and the Applicant were reminded that if they cannot demonstrate the ability to work together professionally the Department may have to consider referring the Licensee and the Applicant for possible administrative action.

The following items are to be provided to the Department by Close of Business Today:
· Updated LIC 500 Personnel Report identifying new administrator and current role of Susanne Anderson, RN residing at the facility.
· LIC 308 Designation of Facility Responsibility documenting Applicant as a facility administrator
· LIC 9182 Criminal Background Clearance Transfer Request and accompanying US government issued ID to be submitted on behalf of applicant and Ms. Anderson.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. (See LIC 809-D)

An exit interview was conducted virtually with Licensee Emerita Garrovillas. A copy of this report, LIC 809, LIC 809-D, and Appeal Rights, were provided to Licensee Emerita Garrovillas via email.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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