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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003842
Report Date: 10/11/2025
Date Signed: 10/11/2025 12:59:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/10/2025 and conducted by Evaluator Samer Haddadin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250210121155
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: 4DATE:
10/11/2025
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Arnold Andal TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not follow Day Staff Ratio implemented by RCOC
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility on October 11, 2025, to deliver findings regarding the above-mentioned allegations. Upon arrival, LPA Haddadin was greeted by Cynthia Castro, Care Staff, who granted access to the facility. The purpose of the visit was explained, and Administrator (AD) Arnold Andel arrived at 11:12 a.m.
The investigation focused on the allegation that the “Facility did not follow the Day Staff Ratio implemented by the Regional Center of Orange County (RCOC).” During the course of the investigation, LPA Haddadin reviewed relevant facility records and conducted interviews with four staff members. All four staff members corroborated the allegation, reporting that only two staff members were working the night of October 10, 2025, through the morning of October 11, 2025.{***CONTINUE*** 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20250210121155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GILBERT CARE HOME-MILAN
FACILITY NUMBER: 306003842
VISIT DATE: 10/11/2025
NARRATIVE
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 During the visit, LPA Haddadin observed four staff members on duty while the facility housed four clients. Client 1 (C1) required a 2:1 staff-to-client ratio, and Client 2 (C2) required a 1:1 staff-to-client ratio. LPA Haddadin observed only one staff member assigned to care for C1 throughout the entire visit.
It was further noted that the facility had previously received a New Referral Moratorium from the Regional Center of Orange County (RCOC) on July 28, 2025. This action was taken following the identification of violations that resulted in the issuance of Corrective Action Plans (CAPs). The prior violations included two Special Incident Reports (SIRs) concerning Client 1 (C1). The first SIR alleged neglect and a failure to protect from a health and safety hazard after C1 used a chair to access a locked, elevated cupboard. According to C1’s Plan of Service (POS), a 2:1 staffing ratio is required twenty-four hours per day, seven days a week. The allegation was substantiated by RCOC as the required second staff member was not present with C1 at the time of the incident.
A second SIR was received on February 7, 2025, alleging a client rights violation due to insufficient staffing, which was observed by a reporting party and C1’s mother on January 28, 2025. An unannounced visit by RCOC and additional representatives on February 10, 2025, determined that staffing levels were inadequate to meet client needs. These findings were discussed with Administrator Noel Villegas and confirmed by the RCOC Associate Director of Housing. The allegation of a client rights violation due to insufficient staffing was also substantiated by RCOC.
Based on the documentation obtained and reviewed by LPA Haddadin, the preponderance of evidence standard has been met. Therefore, the allegation that the “Facility did not follow the Day Staff Ratio implemented by the Regional Center of Orange County (RCOC)” is SUBSTANTIATED. This constitutes a violation of Title 22, Division 6, Chapter 6, Section 85065.5(a)(1).
An exit interview was conducted with facility staff, and a copy of this report, along with appeal rights, was provided to Administrator (AD) Arnold Andel.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250210121155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 10/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/14/2025
Section Cited
CCR
85065.5(a)(1)
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85065.5(a)(1) Day Staff-Client Ratio:“For Regional Center clients, staffing shall be maintained as specified by the Regional Center. Based on record review and interviews,
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Licensee refused to discuss POC and wanted to appeal. However, LPA advised to submit proof of understanding as a POC and send it to LPA by POC due date
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 the facility failed to maintain the staffing ratio required for Client (C1) as specified in the client’s IPP.This poses an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/10/2025 and conducted by Evaluator Samer Haddadin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250210121155

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: 4DATE:
10/11/2025
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Arnold AndalTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not report accurate information to psychiatrist resulting in medication change.
INVESTIGATION FINDINGS:
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{***AMENDED REPORT***}
Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility on October 11, 2025, to deliver findings regarding the above-mentioned allegations. Upon arrival, LPA Haddadin was greeted by Cynthia Castro, Care Staff, who granted access to the facility. The purpose of the visit was explained, and Administrator (AD) Arnold Andel arrived at 11:12 a.m.
The allegation investigated was that the facility provided inaccurate information to the psychiatrist, which resulted in a recommended medication change. The Responsible Party (RP) reported that the psychiatrist recommended increasing Client 1’s (C1) Depakote dosage. The RP stated the RP declined the recommended increase because recent blood work reportedly showed adverse effects that, in the RP’s view, could create a serious health risk if the dosage were increased.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250210121155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GILBERT CARE HOME-MILAN
FACILITY NUMBER: 306003842
VISIT DATE: 10/11/2025
NARRATIVE
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The RP also expressed concern that the facility may have provided inaccurate information to the psychiatrist, which the RP believed contributed to inconsistent Depakote dosing recommendations between the psychiatrist and the neurologist. During record review, Licensing Program Analyst (LPA) Samer Haddadin confirmed the RP holds a limited conservatorship for C1. The court documents reviewed did not indicate the RP has authority to provide or withhold medical consent for C1’s medications or treatment recommendations. The facility reported that the Administrator keeps both treating physicians informed of C1’s condition by providing C1’s medical file to each physician. The facility stated this is done to ensure both doctors are aware of C1’s current condition, recent changes, and the medications C1 is currently taking. The facility further reported it documents medical updates and medication changes in C1’s file to ensure staff have accurate information when coordinating appointments and administering medications. The facility also reported that C1’s conservator continues to accompany C1 to medical; however, the conservator does not have authority to make, direct, or approve any medical decisions. The facility stated that medical decisions are made by the treating physicians in coordination with the facility, consistent with the conservatorship limitations communicated to the facility on April 22, 2025.LPA Haddadin interviewed four staff members. All four denied providing inaccurate information to the psychiatrist and stated they were unaware the RP held a limited conservatorship. LPA Haddadin attempted to interview the RP by telephone; however, after LPA identified himself as a Licensing Program Analyst conducting a complaint investigation, the RP declined to participate. Due to clients’ cognitive and mental disabilities, LPA Haddadin was unable to conduct client interviews. The information obtained during the investigation, including the documents received and reviewed, did not support that inaccurate information was communicated to the psychiatrist.Based on the information obtained, there is insufficient evidence to prove or disprove the allegation. Therefore, the allegation that the “Facility did not report accurate information to the psychiatrist resulting in a medication change” is deemed UNSUBSTANTIATED, meaning that although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.An exit interview was conducted, and a copy of this report was provided to the Administrator. {***AMENDED REPORT***}
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5