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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004178
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:10:49 PM

Document Has Been Signed on 11/15/2022 04:10 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:
11/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Arnold Andal, Administrator, Hermellin Koh, Care Staff and Noel Villegas, LicenseeTIME COMPLETED:
04:10 PM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a Case Management- Incident announced visit for the purpose to following up on an Incident Report received in the Orange Regional Office on 11/15/2022 regarding Staff 1.

LPA Quiroz was greeted by Administrator Arnold Andal and met with Licensee Noel Villegas, Hermellin Koh and Administrator Arnold Andal. During today's case management visit LPA Quiroz along with Administrator Arnold Andal and Licensee Noel Villegas took a tour of the interior and exterior of the facility, restrooms, and all common areas. Upon arrival to the facility LPA Quiroz observed there were three caregivers and Administrator Arnold Andal present in the facility and six clients.

LPA Quiroz inspected food supply adequate amount was observed to be within regulations. The facility has a two-day supply of perishables and seven-day supply of non-perishable food is available as required by regulations. LPA Quiroz observed six clients walking throughout the facility during today's visit with staff supervision. LPA Quiroz observed hallways and walkways were free of obstruction. There are no health and safety concerns observed in the facility.

During today's visit, LPA Quiroz conducted interviews with staff and clients. Staff 1 was not observed to be present in the facility during today's case management visit.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with Licensee Noel Villegas and a copy of this report was provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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