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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800744
Report Date: 12/22/2023
Date Signed: 12/22/2023 12:14:11 PM

Document Has Been Signed on 12/22/2023 12:14 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:CASITAS ESPERANZAFACILITY NUMBER:
197800744
ADMINISTRATOR:JOSE GOMEZFACILITY TYPE:
772
ADDRESS:11925 1/4,1/2 11931 ELLIOTT AVTELEPHONE:
(626) 350-5304
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 13CENSUS: 12DATE:
12/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melanie Gudino, Supervisor TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA arrived and met with Administrator, Shannon Steib.

LPA conducted the remainder of the domains during the visit today:

Staffing: There is sufficient staffing at the facility. There are no clients who rely on staff to perform all activities of daily living.
Personnel Records-Training: The Social Rehabilitation facility has an administrator. Staff files are maintained at the facility. Staff receive on-going training throughout the year and have current first aid training. LPA reviewed (4) personnel files and all have required documentation in their files.
Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed 4 client files and they have the required documents such as the admission agreement, medical assessment with the TB test result, consent forms, and needs/services appraisal plan.
Client Rights - Information: The facility has devices with internet access for clients to use.
Health-Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for 4 clients and staff are administering medications as prescribed.
Incidental Medical Services: There are currently no clients with prohibited or restricted health conditions.
Disaster Preparedness: The Emergency Disaster Plan is current and has the appropriate emergency procedures listed. Facility is conducting monthly disaster drills.

There is no deficiency issued today. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2023
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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