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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800237
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:03:45 PM


Document Has Been Signed on 06/14/2023 12:03 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, 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: 5DATE:
06/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Florife Pagcu, CaregiverTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced case management visit to the facility in response to an incident report received 06/05/2023. LPA met with care staff Florife Pagcu to discuss the report. LPA was put on the phone with administrator Restituto Caliliung and discussed the visit conducted on 06/07/2023 by Anna Bueno, LPA. LPA Goldenberg has determined that no additional information was required and the inquiry into the reported death of resident (R1) is concluded at this time.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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