198601041-9-28-2023-28-AS-CWOG-CW4TBS-20230928143537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601041
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:38:20 PM

Document Has Been Signed on 09/28/2023 02:38 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:	INSIGHT FOR LIVING		FACILITY NUMBER:	198601041
ADMINISTRATOR:	JESSICA MONZON		FACILITY TYPE:	735
ADDRESS:	1524 EAST PUENTE AVENUE		TELEPHONE:	(626) 945-2709
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 5		CENSUS: 3	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Roger Escorcia		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Roger Escorcia and explained the reason of the visit. The facility is approved for serve Developmentally Disabled Adults, five (5) ambulatory clients. The facility is licensed as a 4F home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, still checking client temperature twice a day and staff disinfected the facility every shift. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Environmental and Safety: The facility is a single story house and located on a busy street but residential neighborhood area. The facility includes living room #1, living room#2, kitchen, dining area, den/staff office/client's activity room, three clients bedrooms and two bathrooms, laundry room and a detached garage. Bedroom#1 and #3 has one bed, one drawer, one night stand, one chair, required furniture and bedding and sufficient lighting and closet space. Bedroom#2 has two beds, two chairs, two night stands, two drawers, required furniture and beddings and sufficient lighting and closet space. The two client bathrooms are clean, sanitary and in a good working condition. The two bathrooms hot water were tested between 108.5 and 111.10 degrees F which are within the Title 22 regulation. The appliances in the living room and kitchen are working well. The knives and sharp utensils are stored and locked in the kitchen cabinet (Medication Cabinet).

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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: INSIGHT FOR LIVING	FACILITY NUMBER: 198601041
	VISIT DATE: 09/28/2023

NARRATIVE

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All the chemicals and cleaning supplies are stored and locked in the upper cabinet in the laundry room. The extra linen and personal hygiene products are stored in the hallway cabinet/closet. The facility has a land line telephone system for client to use. The hallway light is always on during night timed for client to access the non-private bathrooms. LPA inspected the carbon monoxide detectors and smoke detectors and they are all working well. The passageway, walkway and patio are free of obstruction.

3. Operational Requirement: The facility is licensed for 5 ambulatory clients and currently all three (3) clients are ambulatory. The last fire/earthquake drill was conducted on 5/3/23. Client is able to attend the community events/activities if there's an opportunity and chance. The facility has a shaded area with table and chairs for client to utilize the outdoor activity.

4.Staffing: The facility has sufficient staffing in the facility. LPA reviewed the NOC shift staff files and she does receive the facility planned emergency procedure training.

5. Personnel Records-Training. The facility staff files are stored in electronic. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Jessica Monzon and her administrator certificate expiration date on 10/31/24 and she has her updated HIV and TB training. LPA reviewed two (2) staff files and they all have the required documents including health screening, TB test result, updated first aid certificate and required training hours.

6. Client right-Information: Currently there's no client required postural support. The facility also served client that has internet service and provide at least one internet access device in the facility.

7. Client Records- Incident Reports: The client files are stored in the staff office in the file cabinet. All client files have the required documents include: face sheet, admission agreement, functional capability assessment, health screening and TB Test, Individual Program Plan (IPP), ambulatory status and medication list.

8. Food Service: Currently no client is on modified diet. The facility has two days perishable and seven days non-perishable food supply. The food are stored probably. The facility refrigerator is maintained within the required temperature.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: INSIGHT FOR LIVING	FACILITY NUMBER: 198601041
	VISIT DATE: 09/28/2023

NARRATIVE

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9. Health Related Services: The medication is centrally stored and locked in the kitchen cabinet. LPA inspected all three (3) clients medication and they all seemed updated and accurate. They all have 30 days supply of medication.

10.Incidental Medical Services: Currently there's no client has any restricted health condition or prohibited health condition in the facility.

11. Disaster Preparedness: The facility has an updated emergency disaster plan and dated on 09/28/23 and the last fire/emergency drill was conducted on 05/03/23 and the facility has two alternative temporary shelter location.

12. Emergency Intervention: The facility does not use any restraint on clients but all staff have an updated CPI training.

No deficiencies were observed during the visit.

Exit Interview conducted and a copy of the report was provided to Roger Escorcia.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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