306002986-1-26-2023-22-AS-AORZ-CNGQKQ-20230127111444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002986
Report Date: 01/26/2023
Date Signed: 01/26/2023 09:26:12 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/14/2021 and conducted by Evaluator Kimberly Lyman

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210614094915

FACILITY NAME:	GILBERT CARE HOME-MARKEV		FACILITY NUMBER:	306002986
ADMINISTRATOR:	NOEL/ARLYN VILLEGAS		FACILITY TYPE:	735
ADDRESS:	1430 S MARKEV STREET		TELEPHONE:	(714) 995-1542
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 4	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Wilfredo Mendoza		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility provided false documents
Facility failed to provide requested documents to responsible party
Facility failed to notify client's doctors of change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry and explained the reason for the visit.

During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as Individual Program Plan (IPP) and weight record. Regarding the allegations that facility failed to notify client's doctors of change in condition, facility failed to provide requested documents to responsible party and facility provided false documents, the investigation revealed the following: Client 1 (C1) had a fall on 01/10/2021 after a seizure. C1 was transported to the hospital via ambulance and was admitted. Per hospital paperwork, C1 was admitted for recurrent seizures with no evidence of intracranial hemorrhage or fracture. Client is required to wear helmet but is not compliant. C1 fell on 01/17/2021 after discharge from the hospital. C1 appeared fine with no injuries. Per facility report, C1's responsible party declined for client to be transported to the hospital. Client fell later that evening with the helmet on and no injuries noted. C1 fell on 06/03/2021 while inside CONTINUED ON LIC 9099C DATED 01/26/2022

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210614094915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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-MARKEV	FACILITY NUMBER: 306002986
	VISIT DATE: 01/26/2023

NARRATIVE

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client bedroom. Client was not wearing helmet as directed. Client was transported to hospital with a laceration on the head and received staples. The client was discharged a few hours later. Facility had been employing a care companion from 10PM to 6AM for client. On 06/04/2021, the care companion was extended to 24 hours with facility paying for 12 hours out of pocket. Multiple 30 day notices have been given to client since 2018 due client's ongoing health and behavioral issues as well as responsible party denying prescribed treatments.. Responsible party states dissatisfaction with all placement's offered to client. Facility provided documentation of behavioral specialists consultations with the client from January 2021 to June 2021. Per documentation from Behavioral Consultant, C1 was being seen in some capacity at least once a month. Five out of six witnesses state facility is communicating all changes in client status to responsible party and physician as well as responding to requests for documents. Client's weight fluctuations and food intake from January 2021 were addressed in a prior complaint, 22-AS-20210122150335 with staff and documents confirming client's weight and food intake were stable. Facility staff's ability to call 911 without Licensee permission was also addressed in prior complaint 22-AS-20210122150335 with staff confirming no permission is needed to call 911. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. 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: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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