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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602450
Report Date: 09/16/2021
Date Signed: 09/16/2021 12:10:58 PM

Document Has Been Signed on 09/16/2021 12:10 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VILLA ESPERANZA - ALLEN HOUSEFACILITY NUMBER:
197602450
ADMINISTRATOR:MARITES BELTRANFACILITY TYPE:
735
ADDRESS:1808 LAS LUNASTELEPHONE:
(626) 405-1722
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 6DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Surya Correa - Direct Support Staff -
Damian Lee - Residential Coordinator		TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit with focus on the infection control domain, food review and medication review. LPA Flores met with Surya Correa direct support staff and explained the reason for the visit. Damion Lee - Residential Director arrived an hour and a half later.

Facility is a single story home and it is licensed to served 6 ambulatory clients between the ages of 18 to 59 years old. Facility has no fences or large bodies of water. Facility has 3 client rooms, 1 staff room, 2 client bathrooms, a living room, a dinning room, a kitchen, a basement inaccessible to clients, a shaded sitting in the front porch and a back yard. LPA Flores observed the following: All client bedrooms have the required bedding and furniture. Bedroom #2 has one working dim lamp and requires additional lighting. LPA tested water temperature in bathroom #1(B1) which tested at 108.8 degrees F and bathroom #2(B2) which tested at 109.0 degrees F, which is within the required temperature of 105 to 120 degrees F. LPA observed facility's kitchen refrigerator and did not observed sufficient perishable food for at least 2 days, observed 7 days of perishable food. Cleaning and disinfectants were locked under the kitchen's sink, and knives were stored in a drawer to the right of the kitchen's sink which was not locked at the time of the visit. Door handle was fell off the exit door to the back yard as client opened the door. Smoke detectors/carbon monoxide detectors were tested and working properly. Fire extinguishers were observed by the kitchen and last checked on 8/21/21. LPA checked Client #1(C1), #2(C2), #3(C3) medication and files. Administrator's certificate # 6033708735 expiration date: 9/4/21 renewal in process. Damion Lee's certification #6030561735 expiration date: 4/2/22.
Facility is following COVID 19 recommendations by posting signs throughout the facility, screening upon entering the facility, staff were observed wearing a face mask, PPE was observed at the facility for at least 30 days, emergency food supplies were observed.

Deficiencies were cited on 809D and technical advisory notes per Title 22 regulations.
Exit interview was conducted with Damion Lee - Residential Coordinator and a copy of this report, 809D, and appeal rights was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 09/16/2021 12:10 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/16/2021 at 11:18 AM
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 - ALLEN HOUSE
FACILITY NUMBER: 197602450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 staff did not lock drawer with knives which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Licensee will provide an in-service training with staff and submit a copy of sign-in and agenda by 9/17/21.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 facility did not ensure to have sufficient perishables for at least 2 days for 6 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Licensee will purchase food, provide a copy of receipt, and picture of food items by 9/18/21.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021


LIC809 (FAS) - (06/04)
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