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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002985
Report Date: 06/28/2022
Date Signed: 06/28/2022 04:40:51 PM

Document Has Been Signed on 06/28/2022 04:40 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:
06/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Alex Mamawal - Direct Support ProfessionalTIME COMPLETED:
04:50 PM
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 Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Gilbert Care Home - Hiawatha. LPA Velazquez was allowed entry into the facility and met with Direct Support Professional (DSP) Alex Mamawal. DSP Felicisimo Tuiza and DSP Marcelo LaQuian were also present. The purpose of today's Case Management visit was to follow-up on an Incident Report received in the Orange Regional Office on June 21, 2022 and again on June 27, 2022 regarding Client (C) #1.


On today's visit LPA Velazquez conducted a phone interview with Administrator Noel Villegas. During the visit LPA Velazquez observed C1 sitting at the dining table eating a snack. LPA Velazquez requested copies of pertinent documentation from C1's file.





There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Direct Support Professional Alex Mamawal and a copy of this report along with the LIC 811s were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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