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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800744
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:33:53 PM

Document Has Been Signed on 01/16/2025 12:33 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASITAS ESPERANZAFACILITY NUMBER:
197800744
ADMINISTRATOR/
DIRECTOR:		JOSE GOMEZFACILITY TYPE:
772
ADDRESS:11925 1/4,1/2 11931 ELLIOTT AVTELEPHONE:
(626) 350-5304
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 13CENSUS: 11DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Shannon Steib TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Glenn Trueman conducted the required annual inspection on 01/16/25. LPA arrived unannounced and met with Administrator Shannon Steib The reason for the visit was explained. The facility is licensed as a social rehabilitation facility to serve mentally disabled adults with a capacity of 13 and ambulatory only. There are currently 11 clients residing at the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility.
Infection Control: Staff are continuing to clean and disinfect each day. They are using appropriate hand hygiene and wearing gloves when necessary to assist clients. The facility has submitted the Infection Control Plan.
Physical Plant & Environment Safety: The facility consists of individual units: Unit #9 consists of 2 client bedrooms, 1 bathroom, and common areas; Unit #3 consists of 2 client bedrooms, 1 bathroom, common areas, and a staff office next door; Unit #8 consists of 2 client bedrooms, 1 bathroom, living room, and kitchen; Unit #4 is an individual client room with a private bathroom; Unit #5 is a library; Unit #6 is utilized as the staffing offices; and the Wellness room is utilized for individual sessions. There are smoke and carbon monoxide combo detectors located in each unit. Cleaning solutions and disinfectants are locked and inaccessible to clients.
Operational Requirements: The facility is adhering to operational requirements. Staff are providing care and supervision to meet the needs of the clients.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin.
Staffing: There is sufficient staffing at the facility. There are no clients who rely on staff to perform all activities of daily living. Interviews were conducted with 3 Staff.
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 (5) personnel files and all have required documentation in their files.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CASITAS ESPERANZA
FACILITY NUMBER: 197800744
VISIT DATE: 01/16/2025
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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. Interviews were conducted with 3 clients.
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.

No deficiencies.

Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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