197602450-7-28-2026-28-AS-DKOI-DWEULW-20260728154124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602450
Report Date: 07/28/2026
Date Signed: 07/28/2026 03:42:14 PM

Document Has Been Signed on 07/28/2026 03:42 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: 5	DATE:	07/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:28 PM
MET WITH:	Marites Gacayan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:50 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced annual using the CARE inspection tool. LPA met with the Administrator, Marites Gayacan and LPA explained the purpose of the visit. Facility is licensed to serve six (6) ambulatory clients between the ages of 18 to 59 years old.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an infection control plan in place. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility.

Physical Plant & Environmental Safety: Facility is a single-story home located in a residential neighborhood and consists of three (3) client bedrooms, one (1) staff room, two (2) client bathrooms, a living room, a dining room, a kitchen, an activity area, a basement inaccessible to clients, a shaded front porch, a front yard, and a back yard. LPA toured the facility and observed that 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 (2) bathrooms were observed clean and in good repair. Water temperature was tested between 105.2 degrees F - 105.9 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. LPA observed extra linens and towels are in the closet near the hallway. LPA observed no large bodies of water. Carbon Monoxide/Smoke detectors were observed. Laundry area was observed clean and in good repair. Sharps are locked and inaccessible to clients. [Continue to LIC809-C]

David Sicairos
Daniel Konishi
	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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: 07/28/2026

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Incidental Medical Services: Per Administrator, none of the clients at this home has a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview and a copy of this report was provided to the Administrator, Marites Gayacan.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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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: 07/28/2026

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Physical Plant & Environmental Safety [Cont.]: Cleaning supplies and toxins are locked and inaccessible to clients. 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 inspected on 4/23/2026.

Operational Requirements: Facility has a fire clearance. The shaded seating area for the clients is provided in the front porch. The facility has a valid Surety Bond and valid Liability Insurance in place. Last Fire Drill was conducted on 7/14/2026.

Staffing: Sufficient staff were observed during the visit. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records - Training: LPA reviewed four (4) staff that includes Personnel Record, Health Screening, TB Clearance, Employee Rights, 1st Aid/CPR/AED training, and Staff Training. Administrator certificate is valid and will expire on 09/04/2027. Administrator has a updated HIV/TB training in file.

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: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. Sufficient food supplies were observed for at least two (2) days of perishables and seven (7) days of non-perishables. No clients have a modified diet. The food is properly stored in the refrigerator.

Client Records - Incident Reports: LPA reviewed five (5) client files which included face sheet, admission agreement, functional capability assessment, physician’s report, TB Clearance, IPP (Individual Program Plan), ISP (Individual Service Plan), and Client Rights. LPA reviewed Clients’ P & I.

Health-Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for five (5) clients to confirm medication is given as prescribed and is documented properly. The facility uses the Quick Medication Administration Record (QMAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. LPA observed the First Aid Kit that had all required items.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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