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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602272
Report Date: 05/28/2024
Date Signed: 05/28/2024 12:12:00 PM

Document Has Been Signed on 05/28/2024 12:12 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
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:
05/28/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:51 AM
MET WITH:Renorman Pascual - Residential CounselorTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility to follow up on deficiency provided on 3/19/24. LPA met with Renorman Pascual and explained the reason fro the visit.

On 3/19/24 LPA Flores conducted a complaint investigation visit and deficiencies on the following were noted:
80065 Personnel Requirements: (a) - Based on licensing not ensure staff was available to supervise Client #1(C1) during the night shift to prevent C1 from consuming foreign bodies. Administrator was to provide a copy of plan created with the regional center to provide additional staffing to the department by POC 3/20/24. On 5/28/24 LPA received a copy of plan created for C1. Deficiency cleared as of 5/28/24.

Exit interview was conducted with Renorman Pascual and a copy of this report and clearance letter 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
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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