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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602094
Report Date: 02/20/2024
Date Signed: 02/20/2024 02:58:27 PM

Document Has Been Signed on 02/20/2024 02:58 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:CLAUDIA CORTEZFACILITY TYPE:
775
ADDRESS:1990 EAST WALNUT STREETTELEPHONE:
(626) 449-2919
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 65CENSUS: 47DATE:
02/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Damion Jackson - Case CoordinatorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores and Christian Gutierrez conducted an unannounced case management visit regarding incident reports submitted to the department on 2/2/24 and 2/7/24. LPAs met with Damion Jackson and explained the reason for the visit.

On 2/2/24 facility submitted an incident report that reported on 2/1/24 client #1(C1) had stated staff #1(S1) had yelled at C1 while asking C1 to pick up beads from the floor.
On 2/7/24 facility submitted an incident report that reported client #2(C2) had been directed by staff #2(S2) to walk to the front lobby for dismissal around 3pm and was found around 3:20pm unsupervised in the facility's van outside.

During the visit LPAs interviewed 2 clients, 4 staff, and S1 and S2 over the phone. Requested copies of personnel record, incident report, staff training, interviews conducted.
Regarding incident on 2/1/24, S1 does not have prior history of yelling at clients. C1 stated S1 was mean but has not yelled at clients. Facility conducted internal investigation and suspended staff on 2/1/24. S1 notified day program that will be retiring and will not return to work. Staff last zero tolerance policy was signed on 2017. No further investigation will be conducted regarding this incident.

Regarding incident 2/6/24, Staff #3(S3) who usually assist with dismissal at around 2:40pm walked by classroom and reminded clients of pick up, two clients followed S3. C2 did not follow staff and stayed with S2. C2 was asked to go to the front lobby for dismissal at around between 2:40pm - 3:00pm by S2. Upon C2's van arrival, S3 realized C2 was not around and staff began to search for C2. C2 was found in a van in the parking lot alone at 3:20pm. Disciplinary action for termination was created for S2 on 2/6/24. Prior given the notice S2 notified they were retiring and not return to work. Per interviews conducted, incident report submitted to the department C2 was left unsupervised for about 20 minutes. Therefore deficiencies are being noted per Title 22 Regulations.
Exit interview was conducted with Claudia Cortez and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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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Document Has Been Signed on 02/20/2024 02:58 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/20/2024 at 02:37 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: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2024
Section Cited
CCR
82065.1(a)(1)

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82065.1 Personnel Qualifications and Duties:(a) The following requirements shall apply to direct care staff as defined in Section 82001(d): (1) Direct care staff shall be responsible for care and supervision of clients, as defined in Section 82001(c).
This requirement is not met as evidence by:
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Program Director conducted training on Participant Supervision on 2/8/24. Deficiency cleared as of 2/20/24.
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Based on interviews and documentation review licensee did not ensure C2 was supervised at all times which poses a potential risk to the heatlh, safety, or personal rights of the persons in care.
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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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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