<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602450
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:37:31 AM

Document Has Been Signed on 07/16/2024 11:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 - ALLEN HOUSEFACILITY NUMBER:
197602450
ADMINISTRATOR/
DIRECTOR:		MARITES BELTRANFACILITY TYPE:
735
ADDRESS:1808 LAS LUNASTELEPHONE:
(626) 405-1722
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:09 AM
MET WITH:Brenda Avila - Residential CounselorTIME VISIT/
INSPECTION COMPLETED:
11:52 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual using the CARE inspection tool. LPA met with Brenda Avila and explained the reason for the visit. Administrator Marites Beltran arrived 15 minutes later.

Facility is licensed to served 6 ambulatory clients between the ages of 18 to 59 years old. Facility is a single story home located in a residential neighborhood and consists of 3 client bedrooms, 1 staff room, 2 client bathrooms, a living room, a dinning room, a kitchen, an activity area, a basement inaccessible to clients, a shaded front porch, a front yard, and a back yard.

LPA Flores conducted a tour of the facility with Brenda Avila and observed the following:
Facility is in good repair indoor and outdoor. No large bodies of water were observed. Facility provides seating area in the covered front porch. Living room, activity area, and dining area have sufficient seating area and in good repair. Each room (3) has sufficient lighting, the required furniture, and bedding supplies. Two bathrooms were observed clean, in good repair. Water temperature was tested in both between 111.1 - 111.4 degrees F., which is within the required temperature of 105-120 degrees F. Kitchen area was observed clean, food supplies were observed sufficient for at least 2 days of non-perishables and 7 days of perishables. Cleaning supplies and sharps were observed locked. Medication for a resident was observed outside the medication box in the refrigerator which is accessible to the clients in care. Backyard was observed clean, passage way to the left of the facility has a few bins that may obstruct passageway. Smoke/Carbon Monoxide detectors were tested and are in working condition. Fire extinguishers were observed and last checked on 8/11/23. First aid kit was reviewed.
LPA reviewed medication, files, and P&I money for 5 clients and 5 staff files. Administrator certificate was reviewed for Marites Beltran #6033708735 exp. date: 9/4/25. Infection and Emergency Disaster plans were reviewed.
Deficiency were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Marites Beltran and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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 3
Document Has Been Signed on 07/16/2024 11:37 AM - It Cannot Be Edited


Created By: Mary G Flores On 07/16/2024 at 11:24 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: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in medication was observed in the refrigerator not stored inside the locked box which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
1
2
3
4
Administrator put the medication in the lock box and will have an informal in-service with staff regarding medication being inaccessible to clients at all times by 7/17/24. Administrator will submit log in to the department by POC due date 7/17/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3