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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602094
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:36:10 PM

Document Has Been Signed on 01/21/2025 04:36 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 SERVICES (DIMENSIONS)FACILITY NUMBER:
198602094
ADMINISTRATOR/
DIRECTOR:		CLAUDIA CORTEZFACILITY TYPE:
775
ADDRESS:1990 EAST WALNUT STREETTELEPHONE:
(626) 449-2919
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 65CENSUS: 49DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:38 PM
MET WITH:Damion Jackson - Case CoordinatorTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the day program using the CARE inspection tool. LPA met with Damion Jackson and explained the reason for the visit.

This facility is licensed as an adult day program to serve a capacity of (65) Developmentally Disabled Adults age 18 to 59. The staff consumer ratio is 1:6 and some of the consumers receive 1:1 supervision .Facility has a lobby, a conference room, 3 offices, 6 classrooms, an activity room, a community room, 2 participant restrooms, a kitchen, a copy room, a staff's restroom. Facility is providing in person services to all participants.

LPA conducted a tour of the facility with Damion Jackson and observed the following:
Facility is in good repair indoor and outdoor. Each classroom is furnished with tables and chairs to allow participants to engage in activities in each room. Women's/Men's bathroom were observed clean and in working condition. Water temperature was tested between 108.6-116.0 degrees F., which is within the required 105-120 degrees F. Water fountain located in the main activity room was observed working. Kitchen area was observed with two refrigerators to stored participants lunch bag. Cleaning supplies, disinfectants, and knives were stored under the sink with a lock. The building has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 7/18/24. First Aid kit was observed.

Infection Control Plan was reviewed which meet most of the requirements. Emergency Disaster Plan was reviewed and has not been updated to the most current LIC610, LPA reviewed emergency disaster plan. However, it does not meet the requirements of LIC610D(12/21).

LPA reviewed 5 participant files and 5 staff files. Two participants do not have medical assessment on file. One staff is missing TB test clearance. Program does not assist with medication or P&I money. Administrator has 30 hours of continuous education.
Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Claudia Cortez and a copy of this report, LIC 809D, and appeal rights will be email due to technical issues.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 3
Document Has Been Signed on 01/21/2025 04:36 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/21/2025 at 04:20 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 SERVICES (DIMENSIONS)
FACILITY NUMBER: 198602094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in staff #1 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator will ensure staff #! has a TB test clearance and a copy is submitted to the department by POC due date 1/31/25.
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in client #1 -#2 do not have a medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator will obtain medical assesment for client #1-#2 and will submit a copy to the department by POC due date 1/31/25.
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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/21/2025 04:36 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/21/2025 at 04:20 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 SERVICES (DIMENSIONS)
FACILITY NUMBER: 198602094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82023(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

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 emergency disaster plan LIC 610D version (12/21) was not review and company's disaster plan does not meet the requirements which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator will submit a copy of LIC 610D (12/21) by POC due date 1/31/25.
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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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