197602272-5-7-2024-28-AS-FFIS-D5WP4C-20240604105855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602272
Report Date: 05/07/2024
Date Signed: 05/07/2024 12:59:37 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
03/22/2024 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240322134110

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:	05/07/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dino Gotladera- Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not reporting incidents to proper agencies.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made a subsequent complaint visit to the facility for the purpose of continuing the investigation and delivering findings. LPA Maldonado met with Administrator, Dino Gotladera, and explained the purpose for the visit.

On 3/28/24, LPA Maldonado made an initial visit to the facility, which consisted of the following: Obtained a copy of the client and staff roster, and obtained the following documents for Clients#1-3 (C1-C3): Facesheet, Physician's Report, current Individual Prorgam Plan (IPP), and Special Incident Reports (SIR) from 2022-2024. LPA also conducted interviews with Staff#1-3 (S1-S3).
On 05/03/24, LPA Maldonado conducted a telephinic interview with C1's placement agency.

During today's visit, LPA Maldonado conducted interviews with Staff# 4 (S4) and C1-C3. A collateral visit to C1's Day Program was made to interview C1, C2 was interviewed at the facility, and C3 was interviewed telephonically.
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240322134110

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: 05/07/2024

NARRATIVE

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The investigation revealed the following:
Regarding allegation: Facility is not reporting incidents to proper agencies.
It is alleged that following incidents that occurred at the facility were not reported to Licensing and to the Regional Center: On 4/10/22- C3 attempted to touch C1 in a "sensual" manner but C1's family and facility staff intervened and redirected C3. On 6/12/22, C3 attempted to kiss C1 on the cheek but C1's family and staff intervened and redirected C3. On 11/06/22, C3 attempted to approach C1 wearing only a towel and underwear, but C1's family and staff intervened and redirected C3. On 10/08/23, C1 was agitated and C3 approached C1 with closed fists, then proceeded to throw a shoe at C1 but C1's family and staff intervened and redirected C3. C2 reported to C1's family that C3 hit C2 on the nose which resulted in C2 needing surgery. On 3/03/24, C3 came out of C3's room with a toy in hand and attempted to throw the toy at C1, but staff intervened and redirected C3. Per interview with C1's placement agency, it was stated that the facility has reported said incidents to the placement agency. However, not all incidents are reportable, as incidents have not resulted in injury and have not endangered C1 in any way. C1's placement agency provided LPA copies of incident reports obtained from the facility. Staff have been able to intervene before the interactions occur without incident. Per staff interviews, (4) of (4) staff denied the incidents are not being reported to the proper agencies. Staff stated that all incidents are documented on consumer reports and client's responsible parties are also notified. Per interview with C1, C1 stated C3 threw a shoe once, but could not corroborate if the shoe was thrown at C1. C1 stated the shoe did not hit C1. C1 could not recall a date or time of the incident. (2) of (3) clients interviewed denied all other incidents occurred. (3) of (3) clients could not corroborate the allegation of incidents not being reported to proper agencies. Clients interviewed stated they get along well with their house mates. Clients also stated staff are nice to them and treat them good. After review of incident reports obtained from the facility and C1's placement agency, the facility has reported incidents to the Licensing agency that are within Reporting Requirements per California Code of Regulations,Title 22.

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.

Per California Code of Regulations, Title 22, Division 6, Chapter 1, Article 06, no deficiencies were cited during today's visit.

An exit interview was conducted and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC9099 (FAS) - (06/04)

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