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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002986
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:14:20 PM

Document Has Been Signed on 03/18/2024 03:14 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GILBERT CARE HOME-MARKEVFACILITY NUMBER:
306002986
ADMINISTRATOR:NOEL/ARLYN VILLEGASFACILITY TYPE:
735
ADDRESS:1430 S MARKEV STREETTELEPHONE:
(714) 995-1542
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
03/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Cristina Bartolome - CaregiverTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced to conduct a health and safety inspection. LPA arrived and was greeted and granted entry by Caregivers Danny Bartolome (CG1) and Cristina Bartolome (CG2).

LPA conducted a tour of the facility. The facility is a one-story home with six client bedrooms, three bathrooms, staff bedroom, kitchen, dining room, living room, family room, backyard and detached garage. LPA observed all of the client rooms to have the necessary furnishings including, bed, chair, closet space and ample lighting. LPA observed facility has a 2-day and 7-day supply of perishables and non-perishables. Facility also has an emergency food and water supply on hand. The facility has three bathrooms. There is one in the entryway (BR1), one down the first hallway (BR2) and one down the second hallway (BR3)

While conducting the tour, LPA observed an unattended chemical spray bottle and coarse scrubber in the BR2 bathtub. CG2 stated clients mostly use BR1 and BR3. LPA stated that, since the clients are able to access the BR2 they are able to access the chemicals. CG2 locked up the chemicals. A deficiency is being issued on this day. LPA observed a client's prescribed medication to be accessible in BR3. LPA obtained a photo of the medication in the cabinet. CG2 locked up the medication. A deficiency is being issued.

LPA measured hot water in all three bathrooms. Hot water in BR1 and BR2 measured at approximately 111 degrees Fahrenheit. Hot water in BG3 measured at approximately 100 degrees Fahrenheit. Based on records reviewed, LPA determined the facility is currently doing weekly water temperature checks in the morning. LPA advised facility adjust water heater and measure in the morning as well as after laundry and showers are done in the afternoon/evening to get a wider, more accurate set of temperatures. A Technical Violation was issued.

Based on today's inspection, two deficiencies and one technical violation are being issued. An exit interview was conducted and a copy of this report, technical violation and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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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Document Has Been Signed on 03/18/2024 03:14 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 03/18/2024 at 02:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GILBERT CARE HOME-MARKEV
FACILITY NUMBER: 306002986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
80075(k)(1)

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Health-Related Services
80075(k)(1) - Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Facility staff locked up the medication during the inspection. AD stated they will re-train the facility staff on centrally storing medication. AD stated that by the POC due date of 4/9/24, they will email LPA the content covered in the training, training attendees and the date and time of training.
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Based on observation, the Licensee did not ensure medication was not accessible to clients due to one client's medication being in an unlocked cabinet. This posed an immediate health and safety risk to persons in care.
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Type B
04/09/2024
Section Cited
CCR80087(g)

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Buildings and Grounds
80087(g) Disinfectants, cleaning solutions, ..., ... and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Facility staff locked up the chemicals during the inspection. AD stated they will re-train the facility staff on safely storing chemicals. AD stated that by the POC due date of 4/9/24, they will email LPA the content covered in the training, training attendees and the date and time of training.
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Based on observation, the Licensee did not ensure potentially dangerous cleaning solutions were not accessible to clients due to one client's medication being in an unlocked cabinet. This posed an immediate health and safety risk to persons in care.
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
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