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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004178
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:09:54 PM

Document Has Been Signed on 05/11/2022 02:09 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 - LULLABYFACILITY NUMBER:
306004178
ADMINISTRATOR:ARNOLD C ANDALFACILITY TYPE:
735
ADDRESS:1512 W LULLABY LANETELEPHONE:
(714) 817-8983
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 6DATE:
05/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Noel Villegas, Arnold Andal, Eva Andal, Benjamin AngoteTIME COMPLETED:
02:20 PM
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On today’s date, Licensing Program Analyst (LPA) LPA Edward Tapia conducted a Case Management-Incident visit with the purpose to discussed Client 1 (C1) elopement behavior and destruction of property which occurred on 5/09/2022.

This is a leveI 4I facility licensed for a capacity of (6) six clients, (1) Non-Ambulatory and (5) Ambulatory clients providing services to Adult clients with Developmental Disabilities.

At 1:20 PM LPA Tapia interviewed Client (C1). LPA Tapia reviewed C1s incident reports and Individual Program Planning (IPP) dated 7/30/2021.

IPP Page 8 of 10, dated 7/21/2021 states (C1) has a history of or attempting running/wandering away less than once per month. (C1( IPP states the following: "Client runs away when he has obtrusive thoughts pop into his head wanting to see his dad in Oregon when he doesn't even know if he really is there or what his actual address is. He’s been asked to talk to staff who can find out this information and make plans for him." C#1 engaged in elopement behavior on the following dates during this year: (01/20/2022, 03/16/2022, 04/09/2022, 05/09/2022)

During today’s visit, LPA Tapia interviewed staff. Staff reported receiving ongoing in-service training on elopement behavior from Behavior Consultant. Staff are able to state designated plan reflecting on (C1) IPP in reference to elopement behavior and destruction.

Staff 1 (S1) encouraged him calm down and reminded client regarding the dangers of elopement. Also, if he has any problems he can always speak to staff for help. Staff contacted 911.

Staff 2 (S2) Stated he approached client and asked to him to come back to the facility.

Staff 3 (S3) asked client if he had a problem. Staff tried to de-escalate the situation.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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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 - LULLABY
FACILITY NUMBER: 306004178
VISIT DATE: 05/11/2022
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Based on today's observations and interviews, there are no citations being cited during today's visit. An exit interview was conducted with Administrator Noel Villegas, and a copy of this report and LIC 811 were provided at exit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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