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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002985
Report Date: 12/05/2024
Date Signed: 01/17/2025 08:53:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
11/06/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20241106161738
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: 4DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Noel Villegas/Arnold Andal - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not ensure that client was free from humiliation that interfered with daily living functions.
Facility did not ensure that all food is safe in quality
INVESTIGATION FINDINGS:
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This is an amended report.
This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegations mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Noel Villegas and Arnold Andal, Administrators and explained the nature of the inspection.

The Department received a complaint on November 6, 2024, stating facility did not ensure that client was free from humiliation that interfered with daily living functions and the facility did not ensure that all food is safe in quality. During the investigation, the Department interviewed Administrator, staff, clients and Day Program staff.
On November 8, 2024, LPA conducted a visit to the facility. LPA obtained photos of the personnel report, client roster, client face sheet, food and text messages.
(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 3
Control Number 22-AS-20241106161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GILBERT CARE HOME-HIAWATHA
FACILITY NUMBER: 306002985
VISIT DATE: 12/05/2024
NARRATIVE
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(continued from LIC9099)

LPA conducted interview with Administrator (AD) Villegas and two staff. AD admitted there was one incident in which Client 1 (C1) was sent to Day Program with soiled clothes from the day before in their backpack. AD reported staff forgot to remove C1’s soiled clothing from the day prior. Two of two staff were unable to confirm or deny that C1 was sent to Day Program with soiled clothes in their backpack. AD and two of two staff stated C1 is normally sent with a change of clothes due to repeated instances of soiling their self. Following the incident AD reported reminding staff to regularly check C1’s backpack prior to attending day program.
On November 25, 2024, LPA conducted a collateral visit to C1's Day Program. LPA conducted interviews with three Day Program staff, of which two staff at the Day Program stated they noticed sometimes C1 would be sent to Day Program with pants that were too big and no belt causing C1’s pants to be falling and the belt not fitting. At least one staff reported C1 would arrive very dirty and would smell. Two staff confirmed having knowledge of C1’s water bottle having mold in it. Interviews conducted report the Day Program advised the facility to clean or replace C1's reusable water bottle due to stains present on the water bottle. Per interviews conducted, once communicated the facility complied.
Based on interviews conducted, LPA determined the facility did not ensure that client was free from humiliation that interfered with daily living functions and the facility did not ensure that all food is safe in quality.

The preponderance of evidence standard has been met. The allegations are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that two violations occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.

LPA was able to verify the facility conducted two in-service training on November 8, 2024 regarding personal rights and safe food service. LPA was able to clear to two deficiencies during the visit. LPA provided clear letters to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241106161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/12/2024
Section Cited
CCR
80072(a)(1)
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80072 PERSONAL RIGHTS (a) Each client shall have personal rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Administrator provided record of a training conducted on 11/8/2024. The training covered client personal rights and dignity and the record provided indicated staff present in the training. The deficiency was cleared during the complaint visit.
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Based on interviews conducted, the facility did not comply with section cited above due to a client being sent to day program with a change of clothes in their backpack. The change of clothes was soiled with urine.
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Request Denied
Type B
12/12/2024
Section Cited
CCR
80076(a)(20)
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80076 FOOD SERVICES (a)(20) All dishes and utensils used for eating and drinking and in the preparation of food and drink, shall be cleaned and sanitized after each usage.

Based on interviews conducted, the facility did not comply with the section cited above
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Administrator provided record of a training conducted on 11/8/2024. The training covered safe food service and the record provided indicated staff present in the training. The deficiency was cleared during the complaint visit.
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due to a client being sent to day program with a stained reusable water bottle.
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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: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3