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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603512
Report Date: 04/15/2022
Date Signed: 04/15/2022 11:01:28 AM


Document Has Been Signed on 04/15/2022 11:01 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:VILLA ESPERANZA - MURPHY HOMEFACILITY NUMBER:
197603512
ADMINISTRATOR:SEGUNDINO GOTLADERAFACILITY TYPE:
735
ADDRESS:2131 DUDLEY ST.TELEPHONE:
(626) 794-2756
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: 4DATE:
04/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Wesley Mair Live in Staff and Administrator Segundino TIME COMPLETED:
11:06 AM
NARRATIVE
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Licensing Program Analysts (LPA) Alberto Lopez and Bennette Pena conducted an unannounced Case management Visit to follow up on a Death Report faxed to the Department on 03/27/22. LPA was met by Live in staff Wesley Mair LPA explained the reason for the visit.

Wesley Mair stated that C1 had been sick since March 11 and took him to urgent care on March 11, 2022 and Urgent care
stated he had low grade pneumonia but documentation of that was not provided.

On 3/27/22 Marvin Untalan DSP knocked on Live in staff Wesley Mair's door around 6:00am and said stated that C1 needs help, Wesley went go to Client#1 (C1) room and C1 was still warm but not breathing. Wesley stated he Called 911 immediately and was told by dispatcher to put C1 on floor and begin CPR. Wesley Did CPR for about 2-3 minutes and paramedics arrived and pronounced C1 deceased and wrapped in white sheet and left about 6:53am. Police arrived 5 minutes after paramedics and asked for death plan. Facility did not have death plan and police called doctor Lillian Ngaw and signed death certificate over the phone. Police called Mountain view Mortuary. Mortuary picked up C1 at 11:35am Wesley Mair stated that resident had pneumonia for about 1 week prior to death and doctor was aware and treating him for it. C2 stated he noticed C1 had been sick for about 1 week, mostly sleeping all day and not eating. C2 stated that staff was checking on C1 periodically

Administrator SEGUNDINO GOTLADERA showed up about 1 hour later and was interviewed by LPA
Administrator collaborated above statement of live in staff.

During today's visit LPA interviewed the Live in staff Wesley Mair and C1's roommate. LPA obtained C1's FACE Sheet, Physician's Report, and Medication Administration Record (MAR) for March 2023.

LPA also toured C1's room. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA will also requested facility to obtain and provide Licensing with C1's Death Certificate upon receipt if available.
Deficiencies observed during today's visit. (see 809D for details)
Exit interview held with Administrator and a copy of the report was provided to the facility
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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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Document Has Been Signed on 04/15/2022 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - MURPHY HOME
FACILITY NUMBER: 197603512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2022
Section Cited

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Resident Records. The record contained in the facility file of client # 1 twas incomplted and missing (MAR) FOR March 2022

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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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