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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 01:16:24 PM

Document Has Been Signed on 05/11/2022 01:16 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Anrnold Andal, Benjamin Agnote Noel VillegasTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Arnold Andal and Benjamin Agnote and stated the purpose of this visit. Administrator Noel Villegas arrived during the visit at 12:35 PM and provided assistance.

The facility is a single level structure and licensed for five ambulatory and one non-ambulatory. This facility offers a Level IV-I service.

About 11:37 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed six clients in care and four staff members on the duty. LPA toured the interior and exterior portions of the facility. There were six private client rooms and two private staff rooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, fire alarms and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and hot water was measured at 112.6 degrees Fahrenheit. Bathroom( 2) was observed to be in good repair and hot water was measured at 112.6 degrees Fahrenheit. Bathroom( 3) was observed to be in good repair and hot water was measured at 112.6 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. . Laundry room was in good repair. Medications and toxins where locked and kept away from residents. Kitchen was in good repair with knifes kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility.
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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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation and no advisory were issued.

LPA Tapia conducted an exit interview with Administrator Noel Villegas and copy of this report was explained and left in the facility.
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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