<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002985
Report Date: 08/16/2021
Date Signed: 08/16/2021 03:11:45 PM

Document Has Been Signed on 08/16/2021 03:11 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:GILBERT CARE HOME-HIAWATHAFACILITY NUMBER:
306002985
ADMINISTRATOR:NOEL/ARLYN VILLEGASFACILITY TYPE:
735
ADDRESS:2151 W. HIAWATHA AVENUETELEPHONE:
(714) 357-5617
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Thoy Tuiza and Arnold AndalTIME COMPLETED:
10:50 AM
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 Analysts (LPAs) Kimberly Lyman and Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Thoy Tuiza. Administrator Arnold Andal and Administrative Assistant Raya Tablang arrived during the visit.

At 9:00 AM, LPAs toured the facility with Caregiver Thoy Tuiza. Facility has 6 clients during today's visit. LPAs observed clients relaxing in the facility. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility takes client temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. Arnold Andal has an administrator certificate expiring on 01/28/2022. The facility mitigation plan has been completed and approved. LPAs observed adequate emergency food and water as well as the first aid kit. Fire extinguisher is charged. LPAs toured the outside grounds and observed the outside visitation area. Exit gate is unlocked and self latching. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and clients are vaccinated for Covid-19. LPAs observed updated client emergency information.

LPA consulted with Administrative Assistant Tablang regarding the importance of maintaining a thirty day supply of PPE at the facility. Additionally, LPA consulted with Administrative Assistant on the importance of providing healthful and fresh food for the clients.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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 1