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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601122
Report Date: 11/23/2021
Date Signed: 11/23/2021 04:08:48 PM

Document Has Been Signed on 11/23/2021 04:08 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:INSPIRATION HOMES IIFACILITY NUMBER:
198601122
ADMINISTRATOR:MARSHA HAYWOODFACILITY TYPE:
735
ADDRESS:6745 GOLDEN WEST AVETELEPHONE:
(626) 445-7959
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 4CENSUS: 3DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marsha Haywood, Licensee / AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve four (4) Developmentally Disabled clients, Ambulatory only, from ages 18-59. Client census is three (3). LPA was allowed entry by the Facility Licensee/Administrator. East LA Regional Center provides case management service to all clients residing in this home. The annual fee is paid. LPA discussed the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain;
a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

LPA toured the facility inside and outside. This is a single-story house consisted of three (3) client bedrooms, two (2) bathrooms, laundry room, living room, kitchen, dining area, activity room, and indoor/outdoor activity areas. Backyard, front yard and hallway area are free of obstruction. Backyard has shaded area and free of debris/ hazard.

The kitchen is clean. Facility has maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops are in working condition. Client bedrooms were checked and closet/drawer space to accommodate each client is available. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. Adequate linen and personal hygiene supply are observed. Bathrooms are clean and operational.

LPA also inspected facility common areas including the kitchen, living room, and dining area. Administrator tested the Smoke Detectors and carbon monoxide detectors. They were operational. Fire drill was conducted on 8/2/2021. Fire extinguisher was fully charged and the last service was on 7/21/21. The first aid kit was fully stocked with a manual.
(-Continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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 2
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: INSPIRATION HOMES II
FACILITY NUMBER: 198601122
VISIT DATE: 11/23/2021
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Comfortable temperature of 73 degree Fahrenheit for clients was maintained. Hot water temperature measured at 108.2 degrees Fahrenheit.

Pesticides/poisons are locked and inaccessible to clients. Sharp tools and knives were locked and inaccessible to clients. Hazardous items were locked and inaccessible to clients.

Medications were centrally stored, locked in a cabinet located in the dining area. Medications were properly logged and current.

Administrator certificate is current and the expiration date is 4/5/2023.



No deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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