306002985-8-6-2025-22-AS-LMOA-DKSVUQ-20250822164506

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002985
Report Date: 08/06/2025
Date Signed: 08/06/2025 02:06:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/13/2024 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240313171654

FACILITY NAME:	GILBERT CARE HOME-HIAWATHA		FACILITY NUMBER:	306002985
ADMINISTRATOR:	NOEL/ARLYN VILLEGAS		FACILITY TYPE:	735
ADDRESS:	2151 W. HIAWATHA AVENUE		TELEPHONE:	(714) 357-5617
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 4	DATE:	08/06/2025
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Noel Villegas		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are physically abusing clients in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Administrator (AD) Noel Villegas and explained the purpose of the inspection.

On March 13, 2024, Community Care Licensing (CCL) received three videos taken approximately two years prior in February of 2022 of Client 1 (C1) being physically assaulted by two caregivers, Staff 1 (S1) and Staff 2 (S2).

Video one depicts the following:
C1 is sitting in a chair with their right foot crossed over their left knee. C1’s hands are down. C1’s arms go up in a protective manner but is not observed engaging in any physical aggression towards S1 standing next them. S1 standing to C1’s right side is heard making a statement that is unintelligible. S1 is observed to hit C1’s right hand a couple of times. (Cont. LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 22-AS-20240313171654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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-HIAWATHA	FACILITY NUMBER: 306002985
	VISIT DATE: 08/06/2025

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

S1 then let’s go of C1 and plugs C1’s nose with their hand. It is not clear if S1 is holding C1’s right hand or not. S1 smacks C1’s left hand, then forcibly grabs C1’s right hand and makes C1 smack themselves in the face three times. S1 drops C1’s hand and walks away.

Video two depicts the following:
C1 is sitting in a chair. C1 looks to the left and can be heard screaming while raising their arms in a flailing motion. C1 stands up from the chair, S1 walks over to C1 and grabs them with two hands on the right arm. C1 continues to scream and tries to pry S1’s hands off their arm while falling onto the chair. C1 attempts to push S1 off and block with their arms as S1 punches C1 three times, smacks their face with alternating hands three times, and plugs C1’s nose for a couple of seconds. S1 then proceeds to walk away.

Video three depicts the following:
C1 is observed to be forcibly pressed with their back against the wall with S1 at their right side and S2 in front of them. S2 is observed to be forcing C1 against the wall with their right forearm pressed against C1’s throat and left arm pushed against C1’s body. S1 starts by punching C1 in the stomach and walks away. S2 continues to restrain C1 against the wall while appearing to knee C1 with their right leg. S2 then proceeds to remove their arms and smack C1 in the face with alternating hands. C1 makes a screaming noise and proceeds to walk to the living room and sit down. S2 is observed to follow C1 and while C1 is sitting, S2 stands over them and smacks C1 again with alternating arms.

During their interview, Administrator (AD) Noel Villegas stated that they were not aware of the physical abuse of C1 until being shown the video by S3. AD stated they not sure how S3 received the video and assumed it was from S5 but was unsure how or who actually recorded the videos. Per AD, they believe S5 may have taken the video because upon questioning some of the staff, they were informed that they suspected S5 took the video of S1 and S2 assaulting C1. AD stated that S1 and S2 are former employees and retired over a year ago and they have not been in contact with them since. AD denied having any knowledge of the physical abuse of C1 prior to being shown the video on March 13, 2024. Per AD, S2 was care staff and S1 provided supplies and groceries to each of the facilities.

S1 and S2 could not be interviewed as their whereabouts remain unknown. (Cont. LIC9099-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20240313171654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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-HIAWATHA	FACILITY NUMBER: 306002985
	VISIT DATE: 08/06/2025

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

During their interview, Staff 3 (S3) stated that they first saw the video about a year ago when Staff 4 (S4) shared it with them. S3 stated they are unaware of who took the video or how S4 obtained the video. Per S3, they shared the video with AD immediately after it was taken however AD did not complete an incident report or report the videos to authorities and instead recommended an in-service training for staff.

During their interview, S4 stated they did not know S2 personally but recalled them delivering supplies, food, and medicine. Per S4, S1 worked with them at the facility, and they never witnessed them hit or harm any of the clients. S4 stated both S1 and S2 no longer work at the facility, and they have not seen them nor had any further contact with them since.

During their interview, S5 identified previous staff, S1 in video one and video two. S5 identified previous staff, S2 in video three. S5 denied any knowledge of who took the videos and stated that they had not seen the first two videos prior but saw the third video about a year ago when S3 sent it to them. S5 stated they deleted the video after viewing it and stated that they had not reported what they viewed. S5 denied ever witnessing any abuse or mistreatment of the clients.

Based on staff interviews and video evidence, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D) and an Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health and Safety Code 1548(f)(1)(A).

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20240313171654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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-HIAWATHA	FACILITY NUMBER: 306002985
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/07/2025 Section Cited CCR 80072(a)	1 2 3 4 5 6 7	(a)... each client shall have personal rights which include...: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	AD stated staff training regarding personal rights will be conducted and a written plan of action ensuring facility clients have personal rights, including to be free from corporal or unusual punishment will be provided to LPA via email by POC date.
	8 9 10 11 12 13 14	Based on video evidence and staff interviews, the licensee did not comply with the section cited above as staff physically abused C1, which posed an immediate safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4