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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602450
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:09:09 PM

Document Has Been Signed on 08/16/2022 03:09 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:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Marites Gacayan - Administrator TIME COMPLETED:
03:30 PM
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Licensing Program Analyst(s) (LPA) Mary Flores and Ya Ting Yang conducted an unannounced annual visit with focus on the infection control domain, food review and medication review. LPAs met with Surrya Correa residential counselor and explained the reason for the visit. Administrator Marites Gacayan arrived 15 minutes 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, an activity area, a basement inaccessible to clients, a shaded sitting in the front porch and a back yard.
LPAs observed the following:
Facility has sufficient food worth at least 2 days of perishables and 7 days of non-perishables. Sharps and chemical solutions are kept under lock in the kitchen. Living, dining, and activity area provide space for social distancing. All client bedrooms have all required furniture, sufficient lighting, and required bedding supplies. Bathrooms were observed to be in good condition and have grab bars, water temperature was tested as follow: bathroom #1(B1) tested at 109.8 degrees F., and bathroom #2(B2) tested at 110.6 degrees F. which is within the required 105-120 degrees F. Smoke detectors were tested and in working condition. Fire extinguisher was observed in a wall located in the activity area and last checked on 8/3/22. Facility's outdoor area is in good condition. PPE supplies were observed for 30 days, facility has signs and is following infection control recommendations. LPAs reviewed 6 clients medication and files and 3 staff files. Administrator certificate for Marites Gacayan was posted #6033708735 with an expiration date of 9/4/23.

No deficiencies were given during this visit.

Exit interview was conducted with Steven Castellanos Residential Counselor and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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