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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800237
Report Date: 06/07/2023
Date Signed: 06/07/2023 11:31:24 AM


Document Has Been Signed on 06/07/2023 11:31 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:GABRIELA CARE HOME INCFACILITY NUMBER:
331800237
ADMINISTRATOR:CALILUNG, RESTITUTOFACILITY TYPE:
740
ADDRESS:1717 TAMARRON DRIVETELEPHONE:
(714) 906-6046
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY:6CENSUS: 4DATE:
06/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:TIME COMPLETED:
11:33 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced case management visit to the facility due to an incident report. LPA met with care staff Florife Pagcu who phoned administrator Restituto Caliliung. LPA explained the purpose of today's visit to staff and administrator. Administrators Cresensia Libita and Restituto Caliliung.

On 06/05/2023, the Department was notified of the death of Resident 1 (R1). During today's visit, LPA Bueno interviewed staff regarding the details surrounding R1's death. LPA collected and reviewed records that are pertinent to R1's death, including:
  • Physician Report
  • Medication and Vitals records
  • Emergency Contact Information
  • Admissions Agreement
  • Face sheet
  • Last hospital discharge document

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Administrator Caliliung.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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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