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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602272
Report Date: 05/23/2023
Date Signed: 05/23/2023 11:45:47 AM

Document Has Been Signed on 05/23/2023 11:45 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
GREATER LA AC/SC, 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:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Renorman Pascual - Residential Counselor TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Renorman Pascual - Residential Counselor and explained the reason for the visit.

The facility is licensed to serve developmentally disabled clients ages 18 thru 59. Ambulatory only. The single story home is located in a residential neighborhood. Consist of 4 client bedrooms, 1 staff bedroom, 2 bathrooms, a laundry area, a kitchen, dining, room, a living room, a detached garage, a backyard, and a front yard.

LPA Flores toured the facility with Renorman Pascual and observed the following:
Facility is good repair inside and outside. No large bodies of water were observed. Backyard has a shaded sitting area. Each client bedroom has sufficient lighting, furniture and bedding required. Smoke/carbon monoxide detectors were tested and in working condition. Bathrooms were observed to be in working condition, water temperature was tested in bathroom #1 at 110.0 degrees F. and bathroom #2 tested at 116.7 degrees F., which is within the required 105-120 degrees F. Kitchen was observe clean and in good repair. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies were observed locked under the sink and knives and sharps were observed locked in a utility box. Medication cart was observed lock in the living room. Living room and dining were observed clean and in good repair. Fire extinguishers were observed and last inspected on 8/3/22. Last fire drill was conducted on 5/3/23. Emergency disaster plan was observed (LIC610D 10/03) which is not the latest version. LPA reviewed medication for 6 clients and P&I money. LPA reviewed files for 5 clients and 5 staff. Administrator certificate was observed for Segundino Gotladera #6008122735 exp. date: 9/4/23, HIV/TB training was missing in administrator's file.
Deficiency was noted on LIC 809D. Exit interview was conducted with Damion Lee Residential Director and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 05/23/2023 11:45 AM - It Cannot Be Edited


Created By: Mary G Flores On 05/23/2023 at 11:15 AM
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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in administrator file did not have a copy of HIV and TB training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2023
Plan of Correction
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Administrator will submit a copy of HIV/TB training to the department by POC due date 6/6/23.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in emergency disaster plan observed was LIC 610 version 10/03 which is not the current version that meets the departments requirements which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Administrator will submit a copy of the current version for the emergency disaster plan by POC due date 5/30/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
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