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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602272
Report Date: 04/29/2025
Date Signed: 04/29/2025 03:13:13 PM

Document Has Been Signed on 04/29/2025 03:13 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: 5DATE:
04/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:43 AM
MET WITH:Bill Marcelino - Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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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 Bill Marcelino Direct Support Staff(DSP) 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.

The following CARE tool domains were reviewed during this visit:

Infection Control: Facility maintains an infection control plan. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility.


Physical Plant & Environmental Safety: LPA toured the facility with Renorman Pascual Direct Support Staff and observed the facility is in good repair indoors and outdoors. Living room/dining room has a fireplace which is covered. Each client bedroom has sufficient lighting, the required furniture and bedding supplies. Two (2) bathrooms were observed clean and in good repair. Water temperature was tested between 125.6 - 114.0 degrees F., which is not within the required 105-120 degrees F. Carbon Monoxide/Smoke detectors were tested and are in working condition. Laundry area was observed detergent was above the washer accessible to the clients. Kitchen was observed clean, cleaning supplies were observed unlocked and accessible to the clients. Passageways and exit areas were observed free of obstructions. No large bodies of water were observed. First aid kit and fire extinguishers were observed.
(CONTINUED ON LIC 809C)
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/29/2025
NARRATIVE
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Operational Requirements: Facility has a fire clearance. The backyard offer shaded seating area for the clients. Garage is not accessible to the clients.
Staffing: Two staff were observed during the visit. Facility vendorizes with Lanterman Regional Center and maintain a 1:3 ratio.
Personnel Records - Training: All staff records were available for review. Each staff has a criminal background clearance. Administrator certificate was observed for Segundino Gotladera #7002210735 exp. 9/4/25. TB/HIV training on file. Five staff files were reviewed which include health screenings, TB test clearance, personnel records, finger clearance, and training. First Aid/CPR training was expired for staff #3 adn #5(S3-S5).
Client Rights - Information: Clients rights were observed posted in the living room. A device with internet access is available. No postural supports were observed.
Food Service: Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Clients do not have special diets. .
Client Records - Incident Reports: All client records were available for review. Files were reviewed for 4 clients, which included medical assessments, admission agreement, individual service plan or needs and care plan, and TB test. Client #2(C2) does not have a TB test clearance on file. Five clients IPPs were not current.
Health-Related Services: Medications were observed centrally stored. A staff assist clients with medication and PRN medications. Staff have a current First Aid/CPR training on file and are responsible for contacting emergency services. Medication was reviewed for 5 clients. C2's medication was observed outside the original container without a label.
Incidental Medical Services: There are no residents with health services needs.
Disaster Preparedness: Emergency Disaster Plan LIC610D (12/21) was observed and last reviewed on 5/26/23. Last emergency drill was conducted on 3/10/25 and are conducted monthly.

LPA interviewed 2 clients and 2 staff. P&I was reviewed for 4 clients.

No deficiencies were noted during this visit.

Exit interview was conducted with Ernesto Vasquez Program Manager and technical violation was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/29/2025 03:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/29/2025 at 02:33 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies: (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 water temperature in bathroom #1 was tested at 125.6 degrees F, which is not within the required 105-120 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Administrator will adjust water temperature and ceritfy to ensure water temperature is maintain within the required 105-120 degrees F., at all times to the department by POC due date 4/30/25.
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.


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 cleaning supplies were observed unlocked and accessible to the client under the kitchen's sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Administrator will provide training to staff on 80087 regulations and will submit a copy to the department by POC due date 4/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2025 03:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/29/2025 at 02:48 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
89970(a)(5)
89970 Client Records
(a) The licensee shall ensure the client records include the following: (5) Current Individual Program Plan;


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 5 out of 5 clients' IPPs were not current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Administrator will request IPPs from Regional Center and submit a copy to the department by POC due date 5/7/25.
Type B
Section Cited
CCR
80075(k)(3)
80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored:
(3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.


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 C2's medication was observed out of original box without a label which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Administrator will provide medication training to staff and obtain original container for C2's medication and submit a copy of training and a picture of container to the department by POC due date 5/7/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/29/2025 03:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/29/2025 at 02:55 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(c)(1)
80069 Client Medical Assessment (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 C2 did 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: 05/09/2025
Plan of Correction
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Administrator will obtian TB test clearance and submit and a copy to the department by POC due date 5/9/25.
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.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
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