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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602272
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:22:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220620085012
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:
06/27/2022
UNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Renorman Pascual - Residential Counselor TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff is over medicating client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Rafael Valdez Residential Counselor and explained the reason for the visit.

The visit consisted of the following: LPA Flores requested a copy of staff/client roster. LPA Flores reviewed medication and files for client #1(C1),#2(C2),#3(C3),#4(C4),#5(C5),#6(C6), requested copies of physician's report, admission agreement, face sheet, and medication sheets for the month of June for all clients and medication training for S1, and S2. LPA interviewed staff #1(S1), #2(S2), C1,C2,C3,C4,C5,C6. LPA Flores. On 6/24/22 LPA Flores contacted Lanterman Regional Center facility's services coordinator.

The investigation revealed the following: Regarding allegation Facility staff is over medicating client. It is alleged "client is put on another psychotropic instead of addressing behavior."
(CONTINUED ON LIC9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20220620085012
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 197602272
VISIT DATE: 06/27/2022
NARRATIVE
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Medication review revealed all medications are label properly and inside bubble pack, medications are stored in a lock medication cart, medications are tracked on monthly medication sheet with staff's initial under the day and dosage provided to clients. Staff do not initial date and leave it blank when clients go out for the weekend. Interviews with staff revealed 2 out of 2 staff stated medication is provided to the clients per dosage prescribed and noted on medication sheet printed by the pharmacy. Interviews with clients revealed 4 out 6 clients interview were unable to provide further information due to cognitive skills and 2 out of 6 clients interview stated to be taking medication prescribed by a physician and not taking additional medications. Documents reviewed for C1 revealed medication sheet for June matches physician's order from April 1, 2021. Physician appointment dated 4/12/22 lists current medications which include the medications listed on June's medication sheet. Staff training was reviewed and provided last on 5/22/22 On 6/24/22 LPA Flores received a return call from Services Coordinator no concerns were shared during the communication.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Renorman Pascual Residential Counselor and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2