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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003842
Report Date: 05/29/2025
Date Signed: 05/29/2025 08:26:57 AM

Unsubstantiated


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
04/08/2025 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20250408155714
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:
05/29/2025
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Judith TanlentoTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision leading to a loss of appetite and subsequent malnutrition
INVESTIGATION FINDINGS:
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On May 29th, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to deliver the findings for the above-mentioned allegations. LPA Haddadin was greeted by care staff, Judith Tanlento, who granted access to the facility, and the purpose of the visit was explained. It was alleged the facility lacked care and supervision resulting in a client suffering malnutrition due to a reported decline in appetite and a subsequent diagnosis of moderate calorie malnutrition of Client (C1). The investigation determined as follows:
In March 2025, C1 began to experience a decline in appetite. By mid-March 2025, C1’s Court appointed Conservator had arranged for a medical evaluation by C1’s Kaiser primary care physician; however, the physician was unable to determine the cause of the appetite loss or provide an immediate solution. Around the same time, C1 reported dental discomfort, leading to a scheduled dental appointment on March 25, 2025, to explore a potential link to the reduced appetite. That same day, C1 was taken to Kaiser Urgent Care for further evaluation. **CONTINUE 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
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 2
Control Number 22-AS-20250408155714
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: 05/29/2025
NARRATIVE
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 As a result, C1’s dental appointment was rescheduled to April 11, 2025. Due to low oxygen levels, C1 was subsequently transferred from Kaiser Urgent Care to the University of California Irvine Medical Center Emergency Department (UCI ED). The following day, March 26, 2025, C1 was transferred from UCI ED to Kaiser Hospital, where a diagnosis of moderate calorie malnutrition was made.
On April 4, 2025, C1 was discharged from Kaiser Hospital and returned to the facility. During the hospitalization, C1’s Seroquel prescription was discontinued, a new prescription for Topamax to stimulate appetite was prescribed instead. Upon C1’s return to the facility, both C1’s Conservator and staff observed an improvement in C1’s eating habits, although the appetite had not fully recovered. Kaiser provided physical therapy services, with a therapist visiting two to three times per week. On April 11, 2025, C1 attended the rescheduled dental appointment and was diagnosed with gum disease. However, no direct correlation between this condition and the loss of appetite was identified. Several days after returning to the facility, C1 began to report abdominal pain accompanied by dark stools. On April 10, 2025, Facility Administrator Noel Villegas arranged for C1 to be transported to the Kaiser Emergency Room for evaluation. Hospital staff conducted various tests, all of which yielded negative results. The treating physician recommended a follow-up appointment with a Kaiser Gastroenterologist (GI Specialist). On April 12, 2025, with C1’s Conservator’s consent, the Administrator sought a second medical opinion from Facility Physician, Dr. Patel, who recommended a prescription for Megestrol to stimulate appetite. However, C1’s Conservator declined this prescription due to concerns about potential adverse effects. A follow-up appointment with a Kaiser Gastroenterologist (GI Specialist) was scheduled for April 28, 2025. Interviews conducted with facility staff reported they consistently offered C1 alternative nutritional options such as yogurt, pudding, fruit, chocolate milk, Gatorade, and Ensure to maintain hydration and nutritional intake, even when C1 refused facility-provided meals. C1’s Conservator, Facility Administrator Noel Villegas , and facility staff engaged in ongoing communication and collaborative discussions regarding C1’s decreased appetite and potential interventions. The documented information confirms that the facility staff actively monitored and addressed concerns regarding C1’s diminished appetite. The facility demonstrated continuous efforts to monitor C1’s health and address concerns related to appetite loss and malnutrition. Based on the preponderance of evidence gathered through conducted interviews, medical record reviews, and all pertinent documentation collected by LPA Haddadin, the allegation of "Neglect/Lack of Care and Supervision leading to a loss of appetite and subsequent malnutrition" is found to be Unsubstantiated. This determination indicates that while the alleged incident may have occurred, or the concerns may be valid, there is insufficient evidence to prove that the alleged violation took place.No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
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