197602450-8-19-2025-28-AS-MGFS-DKPUFM-20250819153258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602450
Report Date: 08/19/2025
Date Signed: 08/19/2025 03:33:08 PM

Document Has Been Signed on 08/19/2025 03:33 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	VILLA ESPERANZA - ALLEN HOUSE		FACILITY NUMBER:	197602450
ADMINISTRATOR/ DIRECTOR:	MARITES BELTRAN		FACILITY TYPE:	735
ADDRESS:	1808 LAS LUNAS		TELEPHONE:	(626) 405-1722
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY: 6		CENSUS: 6	DATE:	08/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:24 PM
MET WITH:	Evelin Romero - Residential Counselor		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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 Evelin Romero and explained the reason for the visit. Administrator Marites Beltran arrived an hour 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. The following CARE tool domains were reviewed during this visit: Infection Control: Facility maintains an infection control plan. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility. Physical Plant & Environmental Safety: LPA toured the facility with Evelin Romero and observed the facility is clean and in good repair indoors and outdoors. Living room, dining room have sufficient seating area. Each client bedroom has sufficient lighting, the required furniture and bedding supplies. Two bathrooms were observed clean and in good repair. Water temperature was tested between 106.3 - 106.8 degrees F., which is within the required 105-120 degrees F. Second dining room was observed clean, a medication cart was observed and emergency food supplies stored in this area. Carbon Monoxide/Smoke detectors were observed. Laundry area was observed clean and in good repair. Kitchen was observed clean, in good repair. Passageways and exit areas were observed free of obstructions. No large bodies of water were observed. Fire extinguishers were observed which were last checked on 5/21/25. (CONT. 809C)

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA ESPERANZA - ALLEN HOUSE	FACILITY NUMBER: 197602450
	VISIT DATE: 08/19/2025

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Operational Requirements: Facility has a fire clearance. The shaded seating area for the clients is provided in the front porch.
Staffing: Sufficient staff were observed during the visit. Facility is vendorizes through Lanterman Regional Center.
Personnel Records - Training: All staff records were available for review. Each staff has a criminal background clearance. Administrator certificate was observed for Marites Gacayan #6033708735 exp. date: 9/4/25. TB/HIV training on file. Five staff files were reviewed which include health screenings, TB test clearance, personnel records, finger clearance, and training. One staff was interviewed.
Client Rights - Information: Clients rights and other posters were observed posted throughout the home. A device with internet access is available. Half bed rails were observed in room #1 a physician's order is on file.
Food Service: Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. No clients have a modified diet.
Client Records - Incident Reports: Client records were available for review. Files were reviewed for 5 clients, which included medical assessments, admission agreement, pre-appraisal, needs and care plan, and TB test. Three clients were interviewed.
Health-Related Services: Medications were observed centrally stored. A staff assist clients with medication and PRN medications. Staff have a current First Aid/CPR training on file and are responsible for contacting emergency services. Medication was reviewed for 5 clients.
Incidental Medical Services: There are no residents with health services needs.
Disaster Preparedness: Emergency Disaster Plan LIC 610D(12/21) was reviewed last updated on 3/9/25. Last emergency drill was conducted on 8/7/25 and are conducted monthly. Emergency food supplies were observed.

No deficiencies were noted during this visit.

Exit interview was conducted with Marites Gayacan Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

LIC809 (FAS) - (06/04)

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