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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603512
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:07:09 PM

Document Has Been Signed on 12/21/2023 02:07 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
GREATER LA AC/SC, 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: 6DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Segundino Gotladera - Administrator TIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Segundino Gotladera and explained the reason of the visit.

The facility is licensed to serve 6 ambulatory clients ages 18-59 years old. Facility is a single home located in a residential neighborhood and consists of (4) client bedrooms (2) client bathrooms, (1) staff bedroom, a living room, kitchen, dining area, laundry room, a detached garage used for storage, a front porch, and a back yard.

LPA toured the facility with Wesley Mair Staff and observed the following:
Facility is in good repair indoor and outdoor. Living room has sitting areas and an area for activities. Medication cart was observed locked and a cabinet with a lock drawer was observed for sharps. Kitchen area was observed clean, cleaning supplies were observed locked under the sink. Food was observed and it is not sufficient for at least 2 days of perishables and 7 days of non-perishables for 6 clients. Refrigerator did not have a thermometer. Each client's room (4) was observed with sufficient lighting, furniture. Each client bed had bedding supplies, however there are not additional bedding supplies to be change when needed. Bathroom's (2) were observed clean and in good repair, cleaning supplies were observed in bathroom #1(B1) under the sink accessible to the clients. Water temperature was tested, B1 tested at 121.8 degrees F., and bathroom #2(B2) tested at 119.6 degrees F., which is not within the required 105-120 degrees F. Laundry area was observed in working condition, detergent and solutions were locked. A sitting area was observed in the front porch and sitting area and umbrella was observed in the back of the house. Smoke/Carbon monoxide were observed and tested. Smoke/carbon monoxide detector on a client's room has the light on but did not turn on. Fire extinguisher was observed in the kitchen and last checked on 8/11/23.

Medication and P&I money was reviewed for 4 clients. Files were reviewed for 5 clients, and 5 staff. Client #5 (C5) was missing TB test results. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 12/21/2023 02:07 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/21/2023 at 01:09 PM
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 - MURPHY HOME
FACILITY NUMBER: 197603512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in cleaning solutions were stored in bathroom's #1 cabinet under the sink an accessible to the clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Staff removed the cleaning supplies from under the sink in bathroom #1 and relocated them to the lock closet in the hallway. Deficiency cleared as of 12/22/23. Administrator will provide in-service training to staff and will submit a copy of sign-in log, with topic, duration of training, and signatures to the department by 12/29/23.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in B1 water temperature was tested at 121.8 degrees F., which is not within the required 105-120 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Administrator will adjust water temperature and certify in writing that will ensure that water temperature is maintain to the required 105-120 degrees F., at all times by POC due date 12/22/23. Administrator will maintain a water log that will record the water temperature in the next 7 days and will submit to the department by 12/29/23.
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: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2023 02:07 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/21/2023 at 01:09 PM
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 - MURPHY HOME
FACILITY NUMBER: 197603512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA did not observed suffiicient food at the facility worth of 7 days of perishables and 2 days of non-perishables which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Administrator will purchase food and will submit copies of receipts and pictures of food supplies to the department by POC due date 12/22/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2023 02:07 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/21/2023 at 01:09 PM
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 - MURPHY HOME
FACILITY NUMBER: 197603512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(g)
Fixtures, Furniture, Equipment, and Supplies
(g) The licensee shall provide linens of various kinds necessary to meet the program of services being offered by the facility and the requirements specified in Chapters 2 through 7.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 set of sheets were observed stored in linen closet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator will obtain additional linens sufficient to replace clients' linens when necessary and will submit a copy of receipt and picture to the department by POC due date 12/28/23.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in administrator's file did not have a copy of HIV/TB training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Administrator will provide a copy of HIV/TB training to the department by POC due date 1/4/23.
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: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


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Document Has Been Signed on 12/21/2023 02:07 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/21/2023 at 01:09 PM
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 - MURPHY HOME
FACILITY NUMBER: 197603512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in client #5 did not have TB test clearance results on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Administrator will provide a copy of TB test clearance to the department by POC due date 1/4/23.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in last fire drill was conducted on 5/2/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator will conduct a fire/emergency drill and will submit a copy of drill to the department by POC due date 12/28/23.
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: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA ESPERANZA - MURPHY HOME
FACILITY NUMBER: 197603512
VISIT DATE: 12/21/2023
NARRATIVE
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Administrator does not have a copy of HIV/TB training which must be conducted every two years, a renewal packet was send to the department on 8/8/23. However, it is not on the system for review. Certificate #6008122735 exp. date: 9/4/23. Administrator will follow up to ensure the packet was received. First Aid/CPR certificates expired on 12/3/23 for Staff #1-#3 (S1-S3).

The facility has an infection control plan submitted to the department on 7/1/22. Disaster plan was reviewed and last updated on 8/2023. Last fire drill was conducted on 5/2/23.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Segundino Gotladera 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: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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