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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602450
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:20:59 PM

Document Has Been Signed on 09/29/2021 02:20 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:
09/29/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marites Gacayan - Administrator TIME COMPLETED:
02:45 PM
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Licensing Program Analyst(s) (LPA)s Mary Flores and Jewel Baptiste conducted a plan of correction visit at the facility to follow up on deficiencies cited on 9/16/21.

On 9/16/21 LPA Flores conducted an unannounced annual visit during the visit the following deficiencies and technical violations were given:

During today's visit LPAs conducted a tour of the facility with Surya Correa caregiver and observed the following corrections for deficiencies cited on 9/16/21:
80087(g)(1) Buildings and Grounds - Licensee did not ensure knives and sharps were kept locked. LPA observed knives/sharps drawer was locked and open during the visit.

85076(d)(1) Food Service - Licensee did not ensure facility had sufficient perishable foods for at least 2 days. LPA observed sufficient perishable foods for at least 2 days during this visit.

80087(a) Buildings and Grounds - Facility's backyard door handle fell down during the visit of 9/16/21. LPA Flores observed door handle was fixed after door was open.

80088(d) Furniture, Fixtures, Equipment, and Supplies - Bedroom #2 did have sufficient lighting during the visit.

Deficiencies have been cleared per Title 22 Regulations.

Exit interview was conducted with Marites Gacayan and a copy of this report, and clearance letter were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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