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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001367
Report Date: 08/22/2022
Date Signed: 08/22/2022 05:55:40 PM


Document Has Been Signed on 08/22/2022 05:55 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:
08/22/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:44 PM
MET WITH:Eric Gilbert, Administrator and Suzanne Maria Stevens Anderson, Live in caregiverTIME COMPLETED:
05:55 PM
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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 Health and Safety Inspection visit.
LPA Quiroz met with Administrator, Eric Gilbert and Live in caregiver Suzanne Maria Stevens Anderson and explained reason for todays visit.

During today's visit, 4 of 4 resident's in care appeared to be safe with no imminent health/safety concerns observed. LPA Quiroz inspected the inside of facility, and no health/safety hazards were observed. Facility was maintained at a comfortable temperature for the residents in care. 4 of 4 Residents at facility were observed to be clean and well groomed. LPA Quiroz inspected facility food supplies. Food supplies were observed to be adequate during this inspection. Hygiene and incontinence care supplies were observed in quantities to meet the needs of residents in care. Staffing was observed to be: 2 live in Caregivers and Administrator Eric Gilbert present during today's visit. AD Eric Gilbert indicated "There was an employment Agency staff working today from 7:30am to 2:30pm."

Live in caregiver 2 indicated "Residents just finished having dinner consisting of: Chicken, eggplant, mashed potatoes, cole slaw, apples, grapes and sugar free cookies for residents who have a diabetes diagnose."

While conducting facility tour in kitchen area, LPA Quiroz observed dinner left-overs as described above.

No deficiencies are being cited during this visit.

An exit interview was conducted with AD Gilbert and Live in Caregiver 2. A copy of this report along with LIC 811s- Confidential names were provided via email due to technical difficulties.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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