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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603512
Report Date: 11/18/2024
Date Signed: 11/19/2024 01:43:08 PM

Document Has Been Signed on 11/19/2024 01:43 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 - MURPHY HOMEFACILITY NUMBER:
197603512
ADMINISTRATOR/
DIRECTOR:		SEGUNDINO GOTLADERAFACILITY TYPE:
735
ADDRESS:2131 DUDLEY ST.TELEPHONE:
(626) 794-2756
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Christian Cabaron-DSPTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst(LPA) S Vaid conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Christian Cabaron-Direct Person Staff and explained the purpose of the visit. Administration Segundino Gotladera arrived shortly after 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 Christian Cabaron Direct Person 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 sufficient for at least 2 days of perishables and 7 days of non-perishables. Each client's room (4) was observed with sufficient lighting and furniture .Observed two client bedrooms locked, client prefer room locked. Each client bed had bedding supplies. Bathroom's (1 and 2) were observed clean and in good repair, Water temperature was tested, B1 tested at 113.8 degrees F., and bathroom #2(B2) tested at 110.7 degrees F.,and kitchen was 118.4 degrees F. which is 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. Fire extinguisher was observed in the kitchen, hallway and next to garage and last checked on 07/03/24.

Medications were reviewed for 6 clients. Files were reviewed for 6 (C1-C6) clients, and 5 (S1-S5) staff.

Continued on 809C.....
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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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 - MURPHY HOME
FACILITY NUMBER: 197603512
VISIT DATE: 11/18/2024
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Administrator and staff have a copy of 1st Aid, CPR and AED trainings. In service training has been conducted every quarter. Certificate #6008122735 exp. date: 9/4/23. Administrator has followed up to ensure the packet was received on 03/05/2024 and is in process.

The facility has an infection control plan submitted to the department on 7/1/22. Disaster plan was reviewed and last updated on 01/03/2024. Last fire/earthquake drills conducted on 10/04/2024.


Exit interview was conducted with Segundino Gotladera and a copy of this report.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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