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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002985
Report Date: 06/06/2022
Date Signed: 06/06/2022 12:16:54 PM


Document Has Been Signed on 06/06/2022 12:16 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:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Administrators-Noel Villegas and Arnold AndalTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an unannounced, required annual visit to facility. LPAs were greeted and granted entry into the facility by administrators (AD) Noel Villegas and Arnold Andal at 11:09 AM.

LPAs De Perio and Marin toured the facility with AD Noel Villegas and Arnold Andal. Facility is licensed for 6 clients, for which 2 can be non-ambulatory. LPAs observed a total of 6 clients in care. LPAs observed that there were 6 ambulatory clients during today's visit.

LPAs toured the exterior and interior portions of the facility. LPAs observed one self-latching exit gate in the backyard. LPAs observed COVID-19 protocols in place as temperatures were checked and universal precautionary signs were posted throughout the facility.

Toilets in restrooms were observed to be operational restroom #1 water temperature was tested and measured at 109.4 degrees Fahrenheit and restroom #2 water temperature was tested and measured 108.8 degrees Fahrenheit. LPAs observed fire extinguisher mounted and fully charged. Smoke detectors and carbon monoxide were tested and operational. Auditory exit alarms were tested to be operational. LPAs observed toxins, cleaning supplies, and knives to be locked and inaccessible to clients. Medications were also locked and inaccessible to clients. LPAs observed that facility had a First-Aid Kit with the required elements and facility had a 30-day supply of PPE. Facility had a 7-day supply of non-perishable food and a 2-day supply of perishable food.

AD Arndol Andal's administrator certificate expires on 01/28/2024, Noel Villegas's administrator certificate expires on 06/13/22, however has submitted for renewal on 04/28/2022 and Arlyn Villegas administrator certificate expires on 05/17/2023.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 06/06/2022
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LPAs reviewed the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Arnold Andal. LPAs discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no citations were issued per Title 22 Division 6 of the California Code of Regulations.

LPAs advised administrators Arnold Andal and Noel Villegas to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov to submit reports, concerns, changes, etc.

LPAs De Perio and Marin conducted an exit interview with facility administrators Arnold Andal and Noel Villegas. LPAs provided copies of this report and advisory notes to administrators.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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