306002983-2-28-2026-22-AS-APAO-DRW68Q-20260305193529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002983
Report Date: 02/28/2026
Date Signed: 02/28/2026 02:48:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2024 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20240912131337

FACILITY NAME:	GILBERT CARE HOME		FACILITY NUMBER:	306002983
ADMINISTRATOR:	NOEL/ARLYN VILLEGAS		FACILITY TYPE:	735
ADDRESS:	10412 GILBERT STREET		TELEPHONE:	(714) 491-1230
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 4	DATE:	02/28/2026
		UNANNOUNCED	TIME BEGAN:	12:28 PM
MET WITH:	Licensee Noel Villegas		TIME COMPLETED:	04:22 PM

ALLEGATION(S):

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-1-Facility staff is testing glucose without meeting required conditions
-2-Licensee is not keeping accurate medical records
-3-Licensee is unable to verify staff trainings
-4-Licensee is not following the Physician orders for the resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to the facility to deliver findings regarding the above-referenced allegations. Upon arrival, LPA Haddadin was greeted by Licensee Noel Villegas, and the purpose of the visit was explained. At the time of the visit, there were four clients in care.
During the investigation, LPA Haddadin reviewed and collected records relevant to the allegations and conducted four staff interviews. The allegations were that “Facility staff is testing glucose without meeting required conditions,” “Licensee is not keeping accurate medical records,” “Licensee is unable to verify staff trainings,” and “Licensee is not following the physician’s orders for the resident.” All four staff interviewed denied all four allegations.
{***CONTINUE9099C***}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240912131337

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GILBERT CARE HOME	FACILITY NUMBER: 306002983
	VISIT DATE: 02/28/2026

NARRATIVE

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During record review, LPA Haddadin verified staff training documentation, including Direct Support Professional (DSP) certifications for each staff member. Staff 1 (S1) held DSP-1 certification dated April 8, 2005, and DSP-2 certification dated June 5, 2007. Staff 2 (S2) held DSP-1 certification dated December 13, 2020, and DSP-2 certification dated March 25, 2025. Staff 3 (S3) held DSP-1 certification dated November 6, 1999, and DSP-2 certification dated August 4, 2001. Staff 4 (S4) held DSP-1 certification dated November 6, 1999, and DSP-2 certification dated August 4, 2001. LPA Haddadin noted the DSP training documentation included training related to medical records, diabetes care, and medication administration. Staff training records also reflected completion of “Best Practices in Monitoring Client Blood Sugar” on August 30, 2024, a two-hour training provided by a BSN nurse Consultant. Records further reflected an additional training provided by BSN nurse Consultant dated September 12, 2024.
LPA Haddadin was unable to interview the clients in care because, due to their medical conditions and non-verbal status, LPA Haddadin could not obtain reliable statements. During the visit, LPA Haddadin observed S1 administering medications to current clients and observed that S1 followed required procedures consistent with DSP training. LPA Haddadin also reviewed Client 1 (C1), a former client of the facility, and confirmed physician orders and medications were followed and documented in the client’s file. Additionally, LPA Haddadin reviewed records for all current clients and confirmed physician orders, including medication orders, were documented in client notes and that medical records for all current clients were maintained accurately, including the records reviewed for C1.
Based on interviews, observations, and record review, the allegations “Facility staff is testing glucose without meeting required conditions,” “Licensee is not keeping accurate medical records,” “Licensee is unable to verify staff trainings,” and “Licensee is not following the physician’s orders for the resident” were determined to be unsubstantiated. Although the allegation may have occurred or may be valid, there was not a preponderance of the evidence to prove or disprove that the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED.
An exit interview was conducted, and a copy of this report was provided to the Licensee.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2026

LIC9099 (FAS) - (06/04)

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