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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003842
Report Date: 07/18/2025
Date Signed: 07/18/2025 03:55:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/13/2024 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240313160913
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:
07/18/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Arnold AndalTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Client sustained fractures due to lack of care and supervision.
Licensee did not ensure facility roof was in good repair.
Licensee did not report incidents to CCL.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analysts (LPAs) Claudia Gutierrez and Edward Kim regarding the allegations mentioned above for the purpose of delivering findings. LPA met with Assistant Administrator (AAD) Arnold Andal and explained the purpose of the inspection. Administrator (AD) Noel Villegas joined by phone.

Regarding the allegation, client sustained fractures while in care due to lack of care and supervision, the following was revealed: During their interview, AD admitted Client 1 (C1) had fallen on June 15, 2022. Per incident report received by Community Care Licensing (CCL) on June 17, 2022, C1 fell in the kitchen of the facility and was transported to West Anaheim hospital, where they were treated for their injury requiring surgery to their left arm due to a fracture. On March 13, 2024, CCL received an incident report indicating that on March 6, 2024, C1 had ran out in the rain and fell. C1 was transported to West Anaheim hospital and treated for their injury consisting of a fracture to their right ankle. (Cont. LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
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 6
Control Number 22-AS-20240313160913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/18/2025
NARRATIVE
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Per Individual Service Plan (ISP) dated July 27, 2023, C1 is diagnosed with Autism, Moderate Intellectual Disability, and Epilepsy, and requires supervision at all times due to impulsive behavior that may result in serious injury. AD reported having little knowledge of what was going on in all six of their facilities and admitted to leaving caregivers in charge of the facilities while AD works from home and occasionally visits a facility for less than half an hour. AD was unable to provide daily logs of the clients and care staff are not documenting change of conditions of the clients or initiating contact with their physicians.

Regarding the allegations, staff did not ensure facility roof was in good repair, and staff did not report incidents to CCL the following was revealed: During their interview, AD stated that on February 22, 2024, Staff 1 (S1) contacted them to notify them that Client 2’s (C2’s) bedroom ceiling had collapsed due to water damage. AD instructed S1 and Staff (S2) to clean the debris and move the client to another room until they could repair the ceiling. Per AD, C2 was uninjured, and they repaired the ceiling within two days after repairing the leaks. Per AD, an incident report was not submitted to CCL after the ceiling collapsed because they did not think it was necessary since no one was injured. During their interview, S1 stated the ceiling had been leaking prior to it collapsing and staff had been using buckets to collect the water, but the buckets would overflow and flood the floor. During their interview, S2 also stated there was a leak coming from the ceiling prior to it collapsing. Per S1 and S2, after the ceiling collapsed, they were initially unable to aid C2 due to debris from the ceiling blocking the doorway allowing access into the bedroom.

Based on AD admission, staff interviews, lack of incident reports submitted, and for unsafe structural damage within the facility placing the clients in harm’s way, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (See LIC9099-D). An Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health and Safety Code 1548(f)(1)(A).

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 22-AS-20240313160913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2025
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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AD stated they will provide LPA with a quality assurance plan to ensure care and supervision is provided as necessary to meet the clients’ needs and is supported by AD and staff schedule via email by POC date
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Based on AD interview, the licensee did not comply with the section cited above as AD admitted to leaving caregivers in charge and care staff are not documenting change of conditions of the clients, which poses an immediate health and safety risks to persons in care.
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Type A
07/21/2025
Section Cited
CCR
80087(a)
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Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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AD stated they will provide LPA with a maintenance plan ensuring structural integrity and physical plant is maintained via email by POC date.
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Based on staff interview, the licensee did not comply with the section cited above as staff stated C2’s ceiling had been leaking prior to it collapsing, which posed an immediate health, safety, and personal rights risks 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20240313160913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2025
Section Cited
CCR
80061(b)(1)(E)
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Reporting Requirements (b)... (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

This requirement is not met as evidenced by:
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AD stated they will provide LPA with a written plan of action to ensure any unusual incident or client absence which threatens the physical or emotional health or safety of any client is reported to CCL within seven days of the occurrence of such event via email by POC date.
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Based on AD interview, the licensee did not comply with the section cited above as AD stated an incident report was not submitted to CCL after the ceiling in C2’s room collapsed, which posed an immediate health, safety, and personal rights risks 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/13/2024 and conducted by Evaluator Claudia Gutierrez
COMPLAINT CONTROL NUMBER: 22-AS-20240313160913

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:
07/18/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Arnold AndalTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff is sedating client in care with unprescribed medications.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analysts (LPAs) Claudia Gutierrez and Edward Kim regarding the allegation mentioned above for the purpose of delivering findings. LPAs met with Assistant Administrator (AAD) Arnold Andal and explained the purpose of the inspection. Administrator (AD) Noel Villegas joined by phone.

Interviews were conducted with seven facility staff regarding the allegation, staff is sedating client in care with unprescribed medications. Five of seven staff stated they do not manage medication and medication is managed by Staff 2 (S2) and S3. During their interview, S2 stated they manage clients’ medication, and medication is administered as prescribed. Per S2, Client 1 (C1) may need a medication adjustment due to napping most of the day and staying up all night. During their interview, S3 stated S2 is primarily responsible for the management of medication. Per S3, medication is administered as prescribed, and they do not believe C1 needs a medication adjustment. (Cont. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
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 6
Control Number 22-AS-20240313160913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/18/2025
NARRATIVE
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During facility annual inspection conducted on May 3, 2024, LPA observed client medication to be locked in a file cabinet. LPA reviewed client medication to be given as prescribed based on doctor’s orders and observed documentation to be consistent with medication for each client. LPA did not observe unprescribed medications within the medication cabinet or unsecured elsewhere in the facility.

Interviews were conducted with four witnesses, who all denied having any knowledge or concerns regarding staff sedating clients with unprescribed medications. Interviews were also conducted with three facility clients, however, due to being non-verbal were unable to confirm or deny allegation.

After a review of client medication and doctor’s orders, and due to conflicting information received during interviews conducted, LPA is unable to determine if staff is sedating client in care with unprescribed medications. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6