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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603512
Report Date: 09/20/2022
Date Signed: 09/20/2022 02:22:45 PM


Document Has Been Signed on 09/20/2022 02:22 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:VILLA ESPERANZA - MURPHY HOMEFACILITY NUMBER:
197603512
ADMINISTRATOR:SEGUNDINO GOTLADERAFACILITY TYPE:
735
ADDRESS:2131 DUDLEY ST.TELEPHONE:
(626) 794-2756
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: 5DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Wesley Mair - Direct Support StaffTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, medication, and food review. LPA met with Wesley Mair Direct Support Staff and explained the reason of the visit. Administrator Segundino Gotladera arrived 15 minutes later.

The facility is licensed to serve 6 ambulatory clients ages 18-59 years old. Facility is a single home located in a residential neighborhood and consists of (4) client bedrooms (2) client bathrooms, (1) staff bedroom, a living room, kitchen, dining area, laundry room, a detached garage used for storage, a front porch, and a back yard.

LPA conducted a tour of the facility with Wesley Mair Direct Support Staff and Segundino Gotlera Administrator and observed the following:
No large bodies of water were observed. Fire extinguishers were observed and last checked on 9/2/22. Smoke/Carbon Monoxide detectors were tested and in working condition. Food supplies were reviewed and sufficient food supplies enough for at least 2 day of perishables and 7 days of non-perishables were observed. Cleaning supplies were locked under sink. Bleach, disinfecting, and other cleaning supplies were observed in a cabinet outside bathroom #1 and was unlocked at the time of the visit. Sharps are kept under lock in cabinet located in living room. Medication was observed in medication cart in living room and lock. Living room has a fire place that is covered. All client rooms have the required furniture, lighting, and bedding supplies. 2 client bathrooms were observed in working condition. Water temperature was tested in bathroom #1(B1) at 128.1 degrees F., and in bathroom #2(B2) at 127.2 degrees F., which is not within the required water temperature of 105-120 degrees F. Medication and files were reviewed for client #1(C1) and #2(C2) and 3 staff files were reviewed. Administrator's certificate # #6008122735 with Expiration date: 9/4/23 was observed. Infection control protocols and prevention are in place. Facility staff have not been fit tested to wear the proper N95.

Deficiencies have been noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Wesley Mair and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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 09/20/2022 02:22 PM - It Cannot Be Edited

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: VILLA ESPERANZA - MURPHY HOME
FACILITY NUMBER: 197603512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in cabinet with bleach, disinfectant, and cleaning supplies was unlock due to lock not working properly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Administrator is to ensure lock is in working condition at all times. Maintenance change the lock during the visit. Deficiency cleared at the time of the visit.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature in B1 tested at 128.1 degrees F. and B2 tested at 127.2 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Administrator will ensure water temperature is maintain at the required temperature at all times and will certify in LIC 9098 by POC due date 9/21/22.

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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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