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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601041
Report Date: 10/07/2022
Date Signed: 10/07/2022 05:59:41 PM

Document Has Been Signed on 10/07/2022 05:59 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:INSIGHT FOR LIVINGFACILITY NUMBER:
198601041
ADMINISTRATOR:ROGER ESCORCIAFACILITY TYPE:
735
ADDRESS:1524 EAST PUENTE AVENUETELEPHONE:
(626) 945-2709
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 5CENSUS: 3DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 AM
MET WITH:Roger Escorcia TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Irayda Perez and explained the reason for the visit. Shortly after, the facility representative Roger Escorcia arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients and staff files.

The facility is a single story house. The facility is included kitchen, dining area, laundry room, a den/staff office/client's activity area, living room, three clients bedrooms and two bathrooms and a detached garage. All 3 clients bedrooms were toured, Bedroom#1 and #3 has one bed, one chair, one night stand, one drawer, required bed linen and furniture and sufficient lighting and closet space. Bedroom#2 has two beds, two chairs, two night stands, two drawers, required bed linen and furniture and sufficient lighting and closet space. All 2 bathrooms were toured and they are clean, sanitary and in a good working condition. The hot water in two bathrooms were tested between 105.4 and 106.5 degrees F. which is within Title 22 regulation. The kitchen cabinet and the refrigerator has the 2 days perishable and 7 days non perishable food supply. The sharp knives and utensils are locked at the kitchen cabinet. All the kitchen appliance are clean and working properly. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded area with tables and chairs for client utilized. LPA inspected the smoke detectors and carbon monoxide detectors and they are all working properly.

LPA reviewed 3 client files to confirm emergency contact is updated. LPA also reviewed 3 staff files and they are all finger print cleared and they also have updated health screening form on their staff personnel file. LPA also inspected all 3 clients' medication and all seemed updated and accurate.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSIGHT FOR LIVING
FACILITY NUMBER: 198601041
VISIT DATE: 10/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility. The disinfecting products are available in the common area and facility is disinfected every shift and frequently, the clients bathrooms have sufficient soap, paper towels, and signs, PPE supplies are sufficient for more than 30 days.

No deficiencies were obserevd during the visit.

Exit Interview conducted. A copy of the report was provided to Roger Escrocia.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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