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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004178
Report Date: 06/15/2023
Date Signed: 06/15/2023 11:56:47 AM

Document Has Been Signed on 06/15/2023 11:56 AM - 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:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Arnold C Andal, Noel VillegasTIME COMPLETED:
12:10 PM
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason Jr. for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Administrator (AD) Arnold C Andal and discussed the purpose of the inspection. Licensee Noel Villegas arrived during the inspection.

LPAs reviewed Infection Control requirements. At about 9:00AM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: this is a one-story home. Facility is a 9-bedroom, 3-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPAs observed 5 staff and 4 clients present at the facility. Client Bedrooms: the 6 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: the 3 staff bedroom are spacious and will easily accommodate the staff’s furnishings. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 108.1 degrees F in the east bathroom, 108.6 degrees F in the north bathroom, and 109 degrees F in the west bathroom. LPAs inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage and in the kitchen. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 10:00AM, LPAs reviewed 6 client files and 5 staff files, interviewed 4 clients and 5 staff, inspected medications for 6 clients, and inspected client money and ledgers for 6 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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Document Has Been Signed on 06/15/2023 11:56 AM - It Cannot Be Edited


Created By: Sean Haddad On 06/15/2023 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GILBERT CARE HOME - LULLABY
FACILITY NUMBER: 306004178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
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Based on observation, 2 out of 5 stove burners could not light by themselves, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/22/2023
Plan of Correction
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Licensee stated they will immediately fix the stove burners and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
85165(b)(2)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records and interview, the licensee did not ensure 5 out of 5 staff have a current CPI certificate, which poses a potential health and safety risk to persons in care.
POC Due Date: 07/13/2023
Plan of Correction
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Licensee stated they will enroll staff in CPI training and submit proof of enrollment to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


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: 06/15/2023
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During the inspection, LPAs and AD observed the following: 5 out of 5 staff did not have current CPI training; and 2 out of 5 stove burners could not light by themselves.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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