306002984-7-18-2023-22-AS-LMAZ-CTUJ5L-20230718064456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002984
Report Date: 07/17/2023
Date Signed: 07/18/2023 06:45:29 AM

Document Has Been Signed on 07/18/2023 06:45 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:	GILBERT CARE HOME-VICTORIA		FACILITY NUMBER:	306002984
ADMINISTRATOR:	NOEL/ARLYN VILLEGAS		FACILITY TYPE:	735
ADDRESS:	1935 W. VICTORIA AVENUE		TELEPHONE:	(714) 491-2171
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 6	DATE:	07/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Arnold Andal		TIME COMPLETED:	01:30 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 Analyst (LPA) Lydia Martinez conducted an unannounced Required - 1 year evaluation. LPA Martinez met and was granted entry by Staff Belen Domingo. Administrator (AD) Arnold Andal was notified and arrived shortly after. Office Assistant Emily Fernando arrived with Staff files and P&I records. AD Andal has a current Administrator Certificate which expires on 01/28/2024. LPA Martinez reviewed whether facility is operating within capacity limitations. Staff Domingo reported census is 6, 1 present, while 5 are at Day Program. Facility is a LeveI 4, licensed for a capacity of 6. The facility is a 1 story home that consist of 3 shared client bedrooms, 1 staff bedroom, 2 bathrooms for clients and staff, living-room, kitchen with dining area, laundry room next to kitchen, a carport and backyard with shaded area. Washer and dryer observed to be functional and operational. LPA, along with Staff Fernando and Domingo conducted a tour of the inside and outside of the facility; all passageways and other areas of potential hazard were inspected. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. LPA observed plenty of hygiene items, such as soap, toilet paper, toothbrush, and toothpaste for the clients. The facility has a clean supply of linen and towels for each client in hallway closet. Hot water temperature in client bathroom was within regulatory requirements. All toxins, sharps and disinfectants were locked in a secured cabinet in between kitchen and laundry room. Kitchen and dining area were inspected. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Facility has a working centralized heater to use for the cold weather and 10 high velocity fans through out the facility, and 2 portable air conditioners for hot weather as needed. Temperature during the visit was 80.2 degrees F. Medication reviewed was labeled and stored and secured in a locked entryway closet. Medication appears to have been dispensed accurately.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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 2

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: GILBERT CARE HOME-VICTORIA	FACILITY NUMBER: 306002984
	VISIT DATE: 07/17/2023

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
26
27
28
29
30
31
32

Staff First Aid and CPR certifications, staff training and medical assessments for staff were reviewed and found to be within Title 22 California Code of Regulations (CCR). LPA reviewed 6 client files, all were found to be within Title 22 CCR and had current Individual Program Plans (IPP). The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

LPA observed Fire Extinguisher was last serviced on 07/06/2022 and is schedule for service on 07/19/2023. Fire drill log reviewed, drills are conducted monthly and last Fire Drill was conducted on 06/13/2023. Smoke and carbon monoxide detectors were tested and found to be operational. First Aid Kit had all required elements. Activity Supplies were observed and available. There are no weapons or bodies of water on the premises. Emergency back packs were observed in a hallway closet and ready to go in an event of an emergency.

Based on observations made, no deficiencies were observed at this time in the areas evaluated. Copy of this report will be sent to email on file.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2