198601041-9-23-2024-28-AS-ALOZ-D9DTDW-20240923143901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601041
Report Date: 09/23/2024
Date Signed: 09/23/2024 02:39:12 PM

Document Has Been Signed on 09/23/2024 02:39 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/ DIRECTOR:	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:	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:31 AM
MET WITH:	Terra Martinez and Roger Escorcia		TIME VISIT/ INSPECTION COMPLETED:	02:57 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Tara Martinez and 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.

Facility is licensed to served 5 adults between the ages of 18-59 years old. Currently there are 2 clients over 60 years of age.

The following was observed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility is disinfecting throughout the day.

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 have 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 nightstands, 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 116.4 and 119.8 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: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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 09/23/2024 02:39 PM - It Cannot Be Edited

Created By: Alberto Lopez On 09/23/2024 at 02:11 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: INSIGHT FOR LIVING	FACILITY NUMBER: 198601041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(b)

Fixtures, Furniture, Equipment, and Supplies

(b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above screen in one room needs to be repaired or which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2024
	Plan of Correction
1 2 3 4	Facility will repair or replace screen by POC date and send proof to LPA.

Type B

Section Cited

HSC

1507(c)(1)(A)

General Provisions

(1) For regional center clients the following shall apply: (A) An individualized health care plan, which may be part of a client's individual program plan, shall be prepared for each client by a health care team that shall include the client or his or her designee if the client is not able to participate in planning his or her health care, the client's primary care physician or nurse practitioner or other health care professional designated by the physician or nurse practitioner, the licensee or licensee's designee, any involved social worker or regional center worker, and any health care professional designated to monitor the client's individualized health care plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. C2 did not have required documentation on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	Facility had the required files stored electronically and provided to LPA during visit. *NO FURTHER ACTION REQUIRED*

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:

Lisa Hicks

LICENSING EVALUATOR NAME:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 09/23/2024 02:39 PM - It Cannot Be Edited

Created By: Alberto Lopez On 09/23/2024 at 02:11 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: INSIGHT FOR LIVING	FACILITY NUMBER: 198601041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(e)

Acceptance and Retention Limitations

(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)]. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, C2 and C3 did not have the LIC602 for Elderly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2024
	Plan of Correction
1 2 3 4	Facility administrator will obtain LIC602 - Residential Care Facilities for the Elderly and send to LPA as proof.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lisa Hicks

LICENSING EVALUATOR NAME:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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: 09/23/2024

NARRATIVE

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3. Operational Requirement: The facility is licensed for 5 ambulatory clients and currently all four (4) clients are ambulatory. The last fire/earthquake drill was conducted on 09/07/24. Clients are 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: A total of six (7) staff members provide care and supervision to the clients.

5. Personnel Records-Training. The facility staff files are stored electronically. 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 is 10/31/24 and she has her updated HIV and TB training. LPA reviewed four (4) 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 has internet service and provide at least one internet access device in the facility.

7. Client Records/Incident Reports: Four (4) client files were reviewed containing admission agreements, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent. 2 clients are over 60 and required the LIC602 Physicians Report for Residential Care facilities for the Elderly.

8. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

9. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Three (3) centrally stored resident medication records were reviewed, one client does not take medications. Centrally stored medications are kept in a safe and locked area and not accessible to clients in care. Medications are given according to Physician orders.

10. Incident Medical and Dental: Client are assisted with medical and dental services.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: 09/23/2024

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11. Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed but facility needs to train staff on location and instructions of shutting off utilities and disaster preparedness.

12. Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit. Technical Advisories provided. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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