197602272-3-19-2024-28-AS-TVAO-D3LT9K-20240322143200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602272
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:12:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/14/2024 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20240314105943

FACILITY NAME:	VILLA ESPERANZA-WAGNER HOUSE		FACILITY NUMBER:	197602272
ADMINISTRATOR:	SEGUNDINO GOTLADERA		FACILITY TYPE:	735
ADDRESS:	1894 WAGNER ST.		TELEPHONE:	(626) 793-2964
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	6	CENSUS: 6	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Renorman Pascual - Residential Counselor		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Client ingested aluminum foil due to lack of care from staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Renorman Pascual and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of staff and clients’ roster. LPA interviewed 5 clients and 3 staff, reviewed food supplies, observed client's room, reviewed clients’ #1-2 (C1-C2) files and requested the following copies: physician’s report, Individual Program Plan (IPP), psychological evaluation, face sheet, consumer notes from January 2024-March 2024, and menus for the last two weeks. LPA contacted Lanterman Regional Center.

The investigation revealed the following: Regarding allegation: Client ingested aluminum foil due to lack of care from staff. It is alleged C1 had ingested the aluminum foil and had vomited 3 or 4 times and it is unknown how C1 got the aluminum foil. (CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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 6

Control Number 28-AS-20240314105943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/19/2024

NARRATIVE

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Interviews with staff revealed the following, C1 has been observed with behavior of compulsive eating disorder recently. Staff have observed C1 wanting to eat non-eating items around C1's environment. Staff have prevented C1 from eating items when observed. However, on 3/9/24 C1 was observed vomiting what seemed to be aluminum foil. C1 may have ingested aluminum foil during the night shift. C1 may have accessed the aluminum foil from the trash and ingested it. Per staff there was no awake staff on duty prior to this incident during the night shift. It was reported to C1’s responsible party who took C1 to the doctor. Documents reviewed revealed, Last IPP dated 9/11/2019 does not note a history of compulsive eating disorder. Facility’s Progress Report dated 1/1/24 notes C1 has behaviors of consuming foreign bodies and staff are using redirection to prevent behavior. Hospital discharge documents for visit on 3/10/24 revealed C1 had evidence of ingesting foreign bodies. Facility has placed a one-on-one staff during the night shift to assist C1 to prevent further incidents of ingesting foreign bodies. Lanterman Regional Center's Service Coordinator is aware of the behaviors and is currently collaborating with facility staff and regional center's team to provide services for C1.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted with Segundino Gotladera and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 28-AS-20240314105943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/20/2024 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	80065 Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator contacted the Regional Center and requested additional staffing assistance by placing a one-on-one during the night shift and a plan has been created to provide supervision for C1 on 3/10/24. A copy of this plan will be provided to the department by POC 3/20/24.
	8 9 10 11 12 13 14	Based on interviews and documents reviewed licensee did not ensure staff was available to supervise C1 during the night shift to prevent C1 from consuming foreign bodies which poses an immediate health, safety, or personal rights risk to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/14/2024 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20240314105943

FACILITY NAME:	VILLA ESPERANZA-WAGNER HOUSE		FACILITY NUMBER:	197602272
ADMINISTRATOR:	SEGUNDINO GOTLADERA		FACILITY TYPE:	735
ADDRESS:	1894 WAGNER ST.		TELEPHONE:	(626) 793-2964
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	6	CENSUS: 6	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Renorman Pascual - Residential Counselor		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not manage client's behavior
Staff are not providing adequate food service
Staff did not safeguard client’s personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Renorman Pascual and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of staff and clients’ roster. LPA interviewed 4 clients and 3 staff, reviewed food supplies, observed client's room, reviewed clients’ #1-2 (C1-C2) files and requested the following copies: physician’s report, Individual Program Plan (IPP), psychological evaluation, face sheet, consumer notes from January 2024-March 2024, and menus for the last two weeks. LPA contacted Lanterman Regional Center.

Regarding allegation: Staff did not manage client's behavior. It is alleged client has yelled, hit, and been (sexual) inappropriate with C1 and staff have not prevented. Interviews with clients revealed, 4 out of 5 clients did not provide answers due to cognitive skills. 1 out of 5 clients stated that client does yells and staff removes video game to redirect client. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20240314105943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/19/2024

NARRATIVE

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Interviews with staff revealed staff stated that client does yell either as a reaction to C1’s behaviors or when frustrated at video games being played. Staff have proceeded to ensure staff stands near hallway to prevent the other client coming in closed distant of C1 when C1 is having a behavior, to prevent interactions between the clients. Also when client yells due to losing game staff puts away game controls to allow client to come down and returns the game in about 30 minutes to manage yelling behavior. Documents reviewed do not revealed any sexual behaviors or history of inappropriate behaviors for questioned client.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff are not providing adequate food service. It is alleged the house menu does not reflect the food that clients’ are eating. Interviews conducted with clients revealed clients are satisfied with the food provided. Interviews with staff revealed staff follow menu to provide food, staff prepare dinner mostly, as clients are out in program during lunch and usually have a sandwich for lunch. LPA observed sufficient food supplies, and a variety of foods such as fruits, vegetables, different types of frozen meats, bread, cereal, and oatmeal. Menu was reviewed and options are based on meal food recommendations and portions.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not safeguard client’s personal belongings. It is alleged personal items such as toys, family photos, and "red" backpack were stolen from C1. Interviews conducted with clients revealed 4 out of 5 clients were unable to answer due to cognitive skills. 1 out of 5 clients stated personal belongings have always been in room and not gone missing. Interviews with staff revealed staff have attempted to prevent C1 from digesting small toys and have stored them in a different area other than C1’s room at times but return it to C1 to take to day program. Per administrator red backpack was observed dirty and in bad shape. Therefore, administrator informed responsible party that will be purchasing a new backpack and discarding the red backpack. Once responsible party visited the facility and the red backpack was observed in the trash, administrator asked staff to wash it and keep it for C1 per responsible party's request. (CONTINUED ON LIC 9099C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20240314105943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/19/2024

NARRATIVE

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LPA observed C1’s bedroom and observed a framed family portrait, a few toys on top of dresser, and a clean red backpack in the closet. During interview with C1 LPA observed C1 carrying a black backpack per staff small toys that C1 likes to carry are inside that backpack.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Segundino Gotladera and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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