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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602272
Report Date: 05/14/2024
Date Signed: 05/28/2024 11:48:23 AM

Document Has Been Signed on 05/28/2024 11:48 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/
DIRECTOR:		SEGUNDINO GOTLADERAFACILITY TYPE:
735
ADDRESS:1894 WAGNER ST.TELEPHONE:
(626) 793-2964
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 6DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Renorman Pascual - Residential Counselor TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Renorman Pascual and explained the reason for the visit.

The facility is licensed to serve (6) 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/living room, a detached garage, a backyard, and a front yard.

LPA conducted a tour of the facility and observed the following:
Facility is clean and in good repair indoor and outdoor. Living room/dining room has sufficient seating area. Medication cart is kept locked. Kitchen area is clean, sharps are kept in a utility box locked. Sufficient food supplies were observed for at 2 days of perishables and 7 days of non-perishables. Six client's bedrooms were observed each with sufficient lighting, the required furniture, and bedding supplies. Facility stores grooming supplies, PPE supplies and linens. Two bathrooms were observed clean, and in good repair. Water temperature was tested in each and tested between 103.0 - 108.3 degrees F., which is not within the required 105-120 degrees F. Laundry area is clean, cleaning supplies are kept in a lock cabinet in this area. Front yard and backyard were observed clean. There is no shaded seating area available. Passageways are clear and free of obstruction. There were no large bodies of water observed. Smoke/Carbon Monoxide detectors were observed and in working condition. Fire extinguishers were observed and last checked on 58/11/23.

Emergency Disaster plan was reviewed last checked on 5/2/24. Infection Control Plan was reviewed.

LPA reviewed medication, P&I money, and files for 6 clients and 5 staff files. Client #1 does not have a TB test on file.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 197602272
VISIT DATE: 05/14/2024
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Administrator certificate was observed for Segundino Gotladera #6008122735 exp. date: 9/4/25. LPA verified administrator certificate certificate is renewed with the department.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Renorman Pascual and a copy of this report, LIC 809D, technical violation/advisory were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2024 11:48 AM - It Cannot Be Edited


Created By: Mary G Flores On 05/28/2024 at 11:33 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: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in a shaded seating area outdoors was not observed during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2024
Plan of Correction
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Administrator will purchase an outdoor seating area and will submit a copy of receipt and picture of area to the department by POC due date 6/4/24.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

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 1 out of 6 clients, Client #1 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator will obtain TB test clearance and submit a copy to the department by POC due date.
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: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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