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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003842
Report Date: 05/03/2024
Date Signed: 05/03/2024 04:31:21 PM

Document Has Been Signed on 05/03/2024 04:31 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-MILANFACILITY NUMBER:
306003842
ADMINISTRATOR/
DIRECTOR:		ROSANNA MAGKAWASFACILITY TYPE:
735
ADDRESS:322 N. MILAN PLACETELEPHONE:
(714) 484-1880
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:36 PM
MET WITH:Noel VillegasTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez, Faith La and Rose Ruppert made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Staff Melania “Mila” David and explained the purpose of the inspection.

During the inspection LPAs and Staff David conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with six client bedrooms, one staff bedroom, two bathrooms, and attached two-car garage. All client bedrooms had the required furnishings. LPAs observed all client beds had linens and blankets. LPAs observed all windows were screened. The backyard has a shaded sitting area. LPAs observed clients resting and watching television in the living room. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.6-107.6 F degrees. LPAs did not observe emergency disaster plan with means of exiting and emergency phone numbers listed and posted; a Deficiency was cited on today’s date. Food menu was posted and visible. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated July 21, 2023. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. LPAs observed used lancets being discarded in an empty vitamin container and container being stored with medication in a locked drawer; a Deficiency was cited on today’s date. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked.

Licensee Noel Villegas arrived at 1:30 p.m. to assist with the inspection. LPAs reviewed four client files and three staff files. Staff files contained documentation for initial staff training and staff training conducted in the past year. LPAs interviewed three clients and three staff. (Cont LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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 05/03/2024 04:31 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/03/2024 at 03:59 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-MILAN
FACILITY NUMBER: 306003842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(3)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:  (3) All staff who are assigned to assist clients with the self-administration of injectable medication shall observe the following procedures:  (B) A syringe and needle shall only be used once per injection on one resident and then properly disposed of in accordance with the California Code of Regulations, Title 8, Section 5193.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff admission, the licensee did not comply with the section cited above, as used lancets are being discarded in an empty vitamin container, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Assistant AD stated they would dispose of all used lancets and obtain a sharps container. Assistant AD stated staff training would be conducted regarding infection control and proper disposal of syringes and needles. Assistant AD stated they would provide LPA with proof via email by POC date.
Deficiency Dismissed
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff admission, the licensee did not comply with the section cited above as an emergency disaster plan was not posted or available for review, which poses a potential safety risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Assistant AD stated they would update emergency disaster plan and have plan posted and available for review. Assistant AD stated they would provide LPA with a copy via email by POC date.
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:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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-MILAN
FACILITY NUMBER: 306003842
VISIT DATE: 05/03/2024
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Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Assistant Administrator Arnold Andal, and a copy of this report and appeal rights were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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