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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800237
Report Date: 04/18/2024
Date Signed: 04/18/2024 11:37:31 AM


Document Has Been Signed on 04/18/2024 11:37 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:
04/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Licensee/Administrator Restituto "Resty" Calilung and Bene MolintasTIME COMPLETED:
11:45 AM
NARRATIVE
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On 04/18/2024 at 08:20 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Resty Calilung to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit on 04/18/2024, Licensing Program Analyst (LPA) Melody Brown observed Staff #3 (S3) working at the facility, providing care and supervision to the residents in care without criminal background clearance. S3 reported to LPA Brown that S3 started working at the facility on 03/29/2024. Licensee/Administrator Restituto "Resty" Calilung confirmed to LPA Brown that the criminal background clearance for S3 was recently submitted pending processing. LPA Brown informed Licensee/Administrator Restituto "Resty" Calilung that deficiency will be issued and Civil Penalties were assessed during the facility visit with the amount of $500.00 and will continue to be assessed of $100.00 per day until corrected for failure to obtain criminal record clearance for S3. Licensee/Administrator Calilung removed S3 at the facility during the visit.

In addition, during the quick tour of the facility, LPA Brown observed Resident #2 (R2) with full bed rail and per interview and documents review, R2's not on hospice and no Exception Letter was submitted and approved by Community Care Licensing Division (CCLD) for R2's full bed rail. Deficiency will be issued. Licensee/Administrator Restituto "Resty" Calilung removed the full bed rail during the facility visit on 04/18/2024.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Restituto "Resty" Calilung.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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 04/18/2024 11:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 INC
FACILITY NUMBER: 331800237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
CCR
87411(g)(1)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance... This requirement is not met as evidenced by:
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Licensee removed S3 at the facility during the visit.
Licensee stated to submit Signed Statement of Understanding on CCR 87411(g)(1) to LPA Brown on Plan of Correction (POC) due date.
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Based on observations, interviews and records review, the Licensee did not comply with section cited above by alowing Staff #3 (S3) to work at the facility without criminal background clearance which poses immediate health, safety and personal rights risks to resident in care.
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Type B
04/30/2024
Section Cited
CCR87608(5)(B)

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87608 Postural Supports (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care... This requirement is not met as evidenced by:
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Licensee removed the full bed rail during the visit on 04/18/2024. Plan of Correction (POC) cleared.
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Based on observations, interviews and records review, the Licensee did not comply with section cited above by allowing R2 to have full bed rail without Exception Letter approved by CCLD or R2 not on hospice care which poses potential health, safety and personal rights risks to resident in care.
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2