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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001367
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:16:49 AM


Document Has Been Signed on 09/14/2022 11:16 AM - 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: 3DATE:
09/14/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Eric Gilbert, Administrator and Emerita Garrovillas, Licensee (Via telephone)TIME COMPLETED:
11:20 AM
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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 Health Check Inspection visit. LPA Quiroz met with Administrator (AD) Eric Gilbert, Live in caregiver 2 and Licensee Emerita Garrovillas (Via telephone) and explained reason for todays visit.
During today's visit, 3 of 3 residents 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. 3 of 3 Residents at facility were observed to be clean and well groomed. On or about 9:28am, LPA Quiroz along with (AD) Eric Gilbert conducted inspection tour of kitchen area, LPA Quiroz observed two refrigerators in kitchen/dining area. LPA Quiroz inspected facility food supplies. Food supplies were observed to be adequate during today's inspection visit. Hygiene and incontinence care supplies were observed in quantities to meet the needs of residents in care. Staffing during today's visit was observed to be: one live in Caregiver, two caregivers and Administrator Eric Gilbert.
During today's visit, on or about 9:33am while touring facility along with (AD) Eric Gilbert, LPA Quiroz observed Caregiver 1 (CG1) not to be wearing their mask. LPA Quiroz provided consultation on PPE requirement due to COVID-19 Pandemic. (CG1)immediately put on mask. (SEE LIC 9102 TV)
LPA Quiroz observed PPE readily available for staff and residents in care in (AD) Headquarters area and facility entrance.
During today's visit LPA Quiroz provided consultation on LIC 602 Form, CCR 87506 Resident Records, CCR 87412 Personnel Records and current licensure capacity for Gentle Care Home. LPA Quiroz read and reviewed email from Orange City Fire Department dated 4/6/2022 and provided consultation on no bedridden approval for this facility at this time.

An exit interview was conducted with (AD) Eric Gilbert, Caregiver 2 and Licensee Emerita Garrovillas via telephone. A copy of this report, LIC 9102 (TV), along with LIC 811s- Confidential names were provided exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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