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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602272
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:47:01 PM

Document Has Been Signed on 03/11/2022 04:47 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VILLA ESPERANZA-WAGNER HOUSEFACILITY NUMBER:
197602272
ADMINISTRATOR:SEGUNDINO GOTLADERAFACILITY TYPE:
735
ADDRESS:1894 WAGNER ST.TELEPHONE:
(626) 793-2964
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 6DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Administrator Segundino GoltaderaTIME COMPLETED:
04:49 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Sarina Roby Caregiver and Administrator Segundino Gotladera arrived short time later. LPA explained the purpose of the visit. Administrator Certificate expires 09/04/2023 fire drill was on 03/01/2022
Structure:
Facility is a single story home and it is licensed to served 6 ambulatory clients between the ages of 18 to 59 years old. Facility has no fences or bodies of water. LPA observed 4 client bedrooms; Bedrooms have all furniture, lighting, and bedding required. 2 client bathrooms; bathrooms had soap, and paper towels available. The passageway and walkways are free of hazard and free from obstruction.
The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Water temperature measured between 105 – 120 degrees F which is within regulation range.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does has one designated isolation room.
· Four client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Four client rooms were equipped with alcohol-based hand sanitizer.
· Five (5) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies were observed during today’s visit. (see 809D)

· Exit interview was conducted with Administrator Segundino Gotladera.. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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 03/11/2022 04:47 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/11/2022 at 04:33 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA ESPERANZA-WAGNER HOUSE
FACILITY NUMBER: 197602272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80057 (b) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. Symptoms, exact dosage, minimum hr between dosages, maximum # of doses allowed in 24 hr period; LPA observed 2 medications without labels.
POC Due Date: 03/14/2022
Plan of Correction
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Administrator will obtian lablels for medications or get distruction order if discuntinued. Administrator will provide training to staff and send copy of log sheet with signatures of staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
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