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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002985
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:25:28 PM

Document Has Been Signed on 07/13/2023 04:25 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:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Arnold AndalTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Required - 1 year evaluation. LPA Martinez met and was granted entry by Staff Teodoro Tablang. Administrator (AD) Arnold Andal was notified and arrived shortly after. Office Assistants Emily Fernando and Hermellin Koh 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 Tablang reported census is 6, 2 present were present while 4 were at Day Program and arrived during this visit.

Facility is a LeveI 4F, licensed for a capacity of 6. The facility is a 1 story home that consist of 3 client shared bedrooms, 1 staff bedroom, 2 bathrooms for clients and staff, living-room, kitchen with dining area, laundry room next to kitchen, 2 car garage that is used for storage only and backyard with shaded area provided by fruit trees. Washer and dryer observed to be functional and operational. LPA, along with Staff Tablang conducted 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 and garage. Hot water temperature in client bathroom was within regulatory requirements. All toxins, sharps and disinfectants were locked in a secured kitchen cabinet 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 and air conditioner to use for the cold or hot weather as needed. The home is maintained at a comfortable temperature for the clients. Medication reviewed was labeled and stored and secured in a locked hallway cabinet. Medication appears to have been dispensed accurately.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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-HIAWATHA
FACILITY NUMBER: 306002985
VISIT DATE: 07/13/2023
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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 07/04/2023. 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 the garage 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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