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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601122
Report Date: 05/12/2025
Date Signed: 05/12/2025 12:51:31 PM

Document Has Been Signed on 05/12/2025 12:51 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:INSPIRATION HOMES IIFACILITY NUMBER:
198601122
ADMINISTRATOR/
DIRECTOR:		MARSHA HAYWOODFACILITY TYPE:
735
ADDRESS:6745 NORTH GOLDEN WEST AVE.TELEPHONE:
(626) 445-7959
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 4CENSUS: 4DATE:
05/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Joseph Haywood, DSP TIME VISIT/
INSPECTION COMPLETED:
12:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual inspection visit. LPA met with DSP Joseph Hayward and discussed the purpose of the visit. The facility is licensed to serve four (4) Developmentally Disabled clients, (age 18-59), and approved for 4 ambulatory clients.

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 Plant & Environment Safety: The facility is a single-story home that contains three (3) bedrooms, one (1) client bathroom, (1) staff bathroom, living room, kitchen, dining room, laundry room, backyard, and shaded patio area. Adequate linen and personal hygiene supply were observed. Bathrooms are clean and operable. . Clients’ bedrooms have beds, dresser and closet space available. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Carbon monoxide detectors and smoke detectors are operable. Hot water temperature measured at 116.2 - 120.0 degrees Fahrenheit which is within range, not all hazardous(detergent) items are locked and inaccessible to clients. Fire extinguishers are fully charged, and last services is 03/11/25. All the window frames need repair and or paint. Two window screens required repair. Dresser in one room is in disrepair and in the same room the floor is lifting and requires repair.



Continued on 809C)
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/12/2025 12:51 PM - It Cannot Be Edited


Created By: Alberto Lopez On 05/12/2025 at 12:12 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: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in. Kitchen drawer is in need of cover, All the window frames outside need repair and/or painting which pose a safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Administrator will repair all he outside window frames and/or paint them. Administrator will repair broken floor in clents Also, will repair the dresser in client's room and the drawer in the kitchen by POC date and send proof to LPA by POC date.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. One container of detergent was accessible to clients during visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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Staff put detergent away 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/12/2025 12:51 PM - It Cannot Be Edited


Created By: Alberto Lopez On 05/12/2025 at 12:12 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: 05/12/2025

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
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Based on observation, the licensee did not comply with the section cited above. Two window screens at the home need adjustment or replacement as they do not align with the window frames which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Administrator will adjust or replace window screens and send proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2025


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: INSPIRATION HOMES II
FACILITY NUMBER: 198601122
VISIT DATE: 05/12/2025
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3. Operational Requirement: The facility is licensed for four (4) ambulatory clients and currently all four (4) clients are ambulatory. Clients can attend the community events/activities if there's an opportunity and chance. The facility has a shaded area with chairs for clients to utilize the outdoor activities.

4) Staffing: A total of two (2) staff members provides care and supervision to the clients during the day. At night there is one (1) staff.

5. Personnel Records-Training. The facility staff files are at facility. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Marshall Haywood, and her administrator certificate expiration date is 04/05/2025. Administrator sent renewal on 05/03/2025 and was asked to forward copy of certificate when received. Administrator has 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. 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.

8. 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, and medical consent.

9. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Four (4) centrally stored resident medication records were reviewed. 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: Clients are assisted with medical and dental services.

11. Disaster Preparedness: The facility has an Emergency Disaster Plan posted at facility but needs updating.



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 Advisory provided. Exit interview held and a copy of the report along with appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC809 (FAS) - (06/04)
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