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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800237
Report Date: 10/16/2026
Date Signed: 10/16/2026 02:33:06 PM

Document Has Been Signed on 10/16/2026 02:33 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GABRIELA CARE HOME INCFACILITY NUMBER:
331800237
ADMINISTRATOR/
DIRECTOR:		CALILUNG, RESTITUTOFACILITY TYPE:
740
ADDRESS:1717 TAMARRON DRIVETELEPHONE:
(714) 906-6046
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY: 6CENSUS: 6DATE:
10/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Administrator Bene MolinitasTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Bene Molinitas and was granted entry to the facility. Licensed capacity is (6) current census (6). LPA was accompanied by Administrator Bene Molinitas to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.There was a designated space for resident/staff files. During facility tour, LPA found multiple pests located in kitchen refrigerator and kitchen cabinets. Deficiency will be issued. Additionally, LPA found scissors and knife located in kitchen drawer not locked. Deficiency will be issued. Moreover, LPA found what appears to be Resident #5 (R5) urine sample located in medication fridge. Staff stated urine is expired. LPA advised that all waste shall be disposed of in a timely manner. Deficiency will be issued.

Food Service: LPA did not observe sufficient non-perishable and perishable food supply. Deficiency will be issued. LPA advised additional food be purchased including fruits and vegetables. Dishes, cups, and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Efren Malagon
Raquel Hernandez
DATE: 10/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GABRIELA CARE HOME INC
FACILITY NUMBER: 331800237
VISIT DATE: 10/16/2026
NARRATIVE
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Record Review: LPA reviewed (6) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed no signed admission agreement for Resident #1 (R1). Deficiency will be issued. LPA reviewed (6) resident medications. LPA observed medication for Resident #2 (R2) was not properly documented on Medication Administration Record (MAR). Deficiency will be issued.

Additionally, LPA observed no signed personal rights documentation for Resident #1 (R1), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). Deficiency will be issued. Moreover, LPA observed no needs and services plan for R1 and R4. Deficiency will be issued. LPA advised all needs and services plan need to be clearly written and need to include full assessment of resident in care. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. No issues were observed.


Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809C) (LIC809D) was discussed and provided to Administrator Bene Molinitas. Along with copy of appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Raquel Hernandez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/16/2026 02:33 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 10/16/2026 at 01:53 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GABRIELA CARE HOME INC
FACILITY NUMBER: 331800237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring all scissors and knives were kept locked inacessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2026
Plan of Correction
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Administrator stated to verbally discuss with facility staff proper storage of all sharps. Administrator will submit to LPA confirmation of proper storage procedures by Plan Of Correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #2 (R2) medication was documented properly in Medication Administration Record (MAR) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2026
Plan of Correction
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Administrator stated medication training was given all facility staff in August 2026. Administrator will verball speak with all facility staff regarding medication documentation. POC will be cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/16/2026 02:33 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 10/16/2026 at 01:53 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GABRIELA CARE HOME INC
FACILITY NUMBER: 331800237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring facility was free of pests, during facility tour LPA observed multiple pests located in kitchen refrigerator and kitchen cabinets, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Administrator stated to submit to LPA pest control receipts by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87303(f)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring Resident #5 (R5) urine sample was disposed of in a timely manner, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Administrator stated to dispose of urine and submit to LPA photo documentation of staff training regarding proper disposal of waste 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.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/16/2026 02:33 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 10/16/2026 at 01:53 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GABRIELA CARE HOME INC
FACILITY NUMBER: 331800237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) signed personal rights documentation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Administrator stated to submit to LPA signed personal rights documentation by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring there was a sufficient amount of non-perishable and perishable food available for all (6) residents in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Administrator stated to submit to LPA photo documentation/receipts of additional food supply 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.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/16/2026 02:33 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 10/16/2026 at 01:53 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GABRIELA CARE HOME INC
FACILITY NUMBER: 331800237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1) admission agreement was signed, which poses a potential personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Administrator stated to submit to LPA a signed admissions agreement by Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1) and Resident #4 (R4) had a completed needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Administrator stated to submit to LPA needs and services plan for R1 and R4 by POC due
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2026


LIC809 (FAS) - (06/04)
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