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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600627
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:15:26 AM

Document Has Been Signed on 11/18/2022 11:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DIMENSIONS DAY PROGRAMFACILITY NUMBER:
198600627
ADMINISTRATOR:GOODUS, DARRYLFACILITY TYPE:
775
ADDRESS:1757 NORTH LAKE AVENUETELEPHONE:
(626) 398-4435
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 75CENSUS: 51DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Director of the Program, Michelle LamTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required annual inspection focusing on the Infection Control domain. LPA met with the Director of the Program, Michelle Lam and explained the purpose of the visit. LPA was checked for covid screening before allowing entry. The program is named Dimensions Day Program but licensed as Villa Esperanza Services. It is an adult day program licensed to serve a total of 40 ambulatory and 35 non ambulatory developmentally disabled clients between the ages of 18 to and 59. Director of the Program stated that the program's current total census is 51, in-person and online participants combined. It is located in the back of the church building and it consists of: lobby, main hall (activity room), kitchen, 2 bathrooms containing stalls and sinks, administrative/staff office, nurse office, clock in/copier room, participant and staff locker room and two (2) participant changing rooms. The Director of the Program and LPA toured the program facility. This program does not supply food, each participant brings their own lunch and does not maintain consumers cash resources.

The following was observed, reviewed and inspected: At 9:30am am, the LPA and the Program Director toured/inspected the physical plant, the main hall/activity room was furnished with tables and chairs that were in good repair and there were tables around with Skills Instructors as they are preparing for a Christmas event for the program. The activity supplies were observed, walls, floors and ceiling were all in good repair, hallway was free of obstructions, toilets and sink was operational, hot water temperature tested in Men's bathroom measured at 116.8 deg. F and Women's bathroom read at 117.8 which are within Title 22 Regulations. ****REPORT CONTINUED ON LIC 809-C*******

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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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: DIMENSIONS DAY PROGRAM
FACILITY NUMBER: 198600627
VISIT DATE: 11/18/2022
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All toxins, medications and sharp objects (scissors) were locked and inaccessible to consumers, carbon monoxide detectors, three (3) fully charged fire extinguishers which were inspected on Feb. 3, 2022. The program has fully stocked first aid kit with tweezers and manual, office and nurses office had furnishing and lighting fixtures as required. During the visit, at 10:00am, technicians were present testing the smoke alarms/detectors. Personal Rights and Reporting Procedures are posted in the locker room. COVID-19 signage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, use of proper PPE, and social distancing. LPA observed that all staff are wearing their masks. There is a PPE storage room that is well stocked, supplies are sufficient for over six (6) months. At 10:15am, LPA randomly selected two (2) participant medications and reviewed the Medication Administration Record (MAR). All medications were centrally stored and locked in the nurse's office. LPA did not observe any deficiencies in this area. Personal hygiene products and extra clothing were observed, both front and back yards were well maintained and free of debris, parking lot was also free of debris, large trash bin with lid observed. Licensing Fees are current, Fire and Earthquake Drills are conducted once a month, emergency drinking water and food were observed.

Per California Code of Regulations, Title 22 and Health & Safety Codes, no deficiencies were observed during today's visit.



An exit interview was conducted with the Director of the Program Michelle Lam and a copy of the report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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