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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003842
Report Date: 03/18/2024
Date Signed: 03/18/2024 04:39:30 PM

Document Has Been Signed on 03/18/2024 04:39 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-MILANFACILITY NUMBER:
306003842
ADMINISTRATOR:ROSANNA MAGKAWASFACILITY TYPE:
735
ADDRESS:322 N. MILAN PLACETELEPHONE:
(714) 484-1880
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
03/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:47 PM
MET WITH:Noel Villegas - AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a Case Management inspection to cite deficiencies observed from an inspection conducted on 3/14/24. LPA was greeted and granted entry into the facility by DSP Lazara Torres. Administrator Noel Villegas joined the inspection for the narrative review.

LPA asked to be shown the client bedrooms. LPA noted a client's bed is on a box spring on the floor in one of the client rooms. AD stated the client's IPP indicated that the bed must be close to the floor for safety due to seizures. AD also stated the client's conservator requested the bed be placed close to the floor for safety. The facility has a bed frame available in the client's room. AD stated that, per the client's Interdiscplinary Team Agreement, the mattress and box spring are not placed on a bed frame, because it too high.

Based on interview with AD and FAS file review, LPA determined the facility did not submit to Community Care Licensing a waiver request to put the bed and box spring on the floor. A deficiency is being issued on this day.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report and appeal rights were provided.
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 04:39 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 03/18/2024 at 04:04 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: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/19/2024
Section Cited
CCR
80024(b)(2)

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Waivers and Exceptions
80024(b)(2) The applicant or licensee shall submit to the licensing agency a written request for a waiver or exception, together with substantiating evidence supporting the request.
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AD stated that they will submit to Licensing a written request for an exception, together with substantiating evidence supporting the request. LPA stated that the request must be fulfilled by the close of the business day on 3/19/24.
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Based on FAS record review and interview with AD, LPA determined the Licensee did not submit to the licensing agency a written request for a waiver or exception, together with substantiating evidence supporting the request. This poses a potential safety or pesonal rights 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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