<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601122
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:51:31 PM

Document Has Been Signed on 05/24/2022 04:51 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 NORTH GOLDEN WEST AVE.TELEPHONE:
(626) 445-7959
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 4CENSUS: 4DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Lidia Casala - House Manager TIME COMPLETED:
05:05 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(s)(LPA) Mary Flores and Valeria Maldonado conducted an unannounced annual visit at the facility with focus in infection control, medication, and food review. LPAs met with Lidia Casala House Manager and explained the reason for the visit.

Facility is licensed to serve four (4) Developmentally Disabled clients, Ambulatory only, from ages 18-59. This is a single-story house consisted of three (3) client bedrooms, two (2) bathrooms, laundry room, living room, kitchen, dining area, activity room, a backyard, and front yard.

LPAs conducted a tour with Lidia Casala House Manager and observed the following:
Smoke/Carbon Monoxide detectors interlace were observed, tested, and in working condition.
Kitchen was observed to have sufficient food for at least 2 days worth of perishable and 7 days of perishable. Sharps and cleaning solutions were observed in a cabinet in the kitchen and locked. All bedrooms have sufficient lighting, required furniture, and bedding. Bathrooms were observed, water temperature was tested as follow bathroom #1(B1) at 108.9 degrees F., and bathroom #2(B2) at 106.2 degrees F., which is within the required 105-120 degrees F. Medication and files were reviewed for client #1(C1) and #2(C2), No physician report was observed for C1. Staff files were reviewed for staff #1, #2,#3. Upon reviewing staff associations to the facility, it was observed staff #4(S4) is not associated to the facility. S4 has been working at the facility since April 1, 2020. COVID recommendations were observed visitor screening, signs for symptoms and encouraging proper sneeze, cough etiquette, hand washing signs need to be updated in all bathrooms, a hand towel was observed in bathroom #2 LPA advice towel to be replaced with paper towels. Current PINs must be posted at the facility.

Deficiencies were noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Lidia Casala House Manager and a copy of this report, LIC 809D, technical adivisory notes, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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 7
Document Has Been Signed on 05/24/2022 04:51 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/24/2022 at 04:13 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: INSPIRATION HOMES II
FACILITY NUMBER: 198601122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

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 in 1 out of 2 clients file reviewed, client #1 does not have a physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
1
2
3
4
Administrator will submit a copy of C1 physician's report to the department by POC due date 6/1/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/24/2022 04:51 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/24/2022 at 04:18 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: INSPIRATION HOMES II
FACILITY NUMBER: 198601122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)

80019 Criminal Record Clearance
(e) All Individuals subject to a criminal record review pursuant to Health and Safety Code sEction 1522 shall prior to working, residing or volunteering in a license facility; (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and document review, the licensee did not comply with the section cited above in 1 out of 3 staff, staff #4 present at the facility was not associate to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
1
2
3
4
Licensee will associate Staff #4 to the facility and submit a copy of association using Guardian Portal by POC due date 5/25/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
Page: 7 of 7