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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601265
Report Date: 07/06/2022
Date Signed: 07/22/2022 04:43:05 PM

Document Has Been Signed on 07/22/2022 04:43 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:INSIGHT FOR LIFEFACILITY NUMBER:
198601265
ADMINISTRATOR:JESSICA MONZONFACILITY TYPE:
735
ADDRESS:606 N. LEAF AVETELEPHONE:
(626) 339-1016
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Roger Escrocia TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Maria Sanchez and explained the reason for the visit. Shortly after, the facility representative Roger Escorcia arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed resident files.

The facility is a single story house and located in a residential neighborhood area. The facility consists of kitchen, laundry room, dining area, second living room, living room, office/activity room, three clients bedrooms and two bathrooms and a detached garage. All 3 clients bedrooms were toured. Bedroom#1 and #3 has one bed, one chair, one drawer, required linen and furniture and sufficient closet space and lighting. Bedroom#2 has two beds, two drawers, required linen and furniture and sufficient closet space and lighting. The two bathrooms were toured and they are all clean, sanitary and in a working condition. The hot water temperature was tested at the two bathrooms are between 115.3 and 120 degrees F which is within the Title 22 regulation. The refrigerator and the kitchen cabinet has sufficient food for two days perishable and seven days non-perishable. All the kitchen appliances are working properly. All the knives and sharp utensils are locked in the medication cabinet near the laundry room. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard also has shaded area and sitting area for clients to utilize. All the cleaning supplies and chemicals are stored in a locked cabinet next to the bathroom#1. The carbon monoxide detectors and smoke detectors are inspected and they are all working well.

LPA reviewed all 4 clients files to confirm emergency contact is updated. LPA also reviewed 4 clients medications. The medications are centrally stored and all four clients medication are seemed accurate and and up-to-dated.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSIGHT FOR LIFE
FACILITY NUMBER: 198601265
VISIT DATE: 07/06/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each clients room and common area and facility is disinfected every shift, the bathrooms have sufficient soap, paper towels, and signs, PPE supplies are sufficient for more than 30 days.

Exit Interview conducted and a copy of the report was provided to staff representative.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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