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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601265
Report Date: 07/22/2023
Date Signed: 07/22/2023 12:10:43 PM

Document Has Been Signed on 07/22/2023 12:10 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 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:
07/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Roger Escorcia-Assistant AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Luisa Perez (Caregiver) and Roger Escorcia (Assistant Administrator) who later assisted with the visit. The purpose of the visit was explained upon arrival. The facility is licensed to serve 4 Ambulatory Developmentally Disabled Adult Adults, ages 18-59 years old.

The facility is located in a residential area in West Covina, Ca. There are 3 bedrooms (2 individual rooms, 1 shared room), 2 bathrooms, living room, dining room, kitchen, laundry area, office (in den), back yard with shaded patio, and an detached garage.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: There are 3 bedrooms, 2 bathrooms, kitchen, laundry area, dining room, office area, detached garage and outside patio. All client bedrooms had the required furniture for comfort and safety and had sufficient lighting. All outdoor passages were free of obstruction. Bathrooms were clean, toilets and water faucets worked properly. Water temperature was measured throughout the client bathrooms and temperatures ranged from 129.8 – 133.8 degrees F, upon arrival. Client bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a locked supply cabinet. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed to be fully charged.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2023
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 07/22/2023 12:10 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/22/2023 at 11:30 AM
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 LIFE
FACILITY NUMBER: 198601265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 as water temperatures in both client bathrooms ranged between 129.8-133.8 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2023
Plan of Correction
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Licensee/Administrator to create a water log starting 07/22/2023 and record water temperature readings every 8 hours for the next 3 calendar days, ending on 07/25/2023. Licensee/ Administrator will send proof of water temperature log to LPA via email. First record of water log on 07/22/23 and subsequent recorded readings must measure within 105 -120

**NOTE: Assistant Administrator Roger Escorcia immediatly lowered water temperature during visit**
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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2023 12:10 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/22/2023 at 11:30 AM
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 LIFE
FACILITY NUMBER: 198601265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA oberved that there were not any facility admission agreements for clients in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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The Licnesee/Administrator will ensure to provide a copy of signed and dated admission agreement with all required information indicated on section code listed above. The Licensee/Administrator will provide a copy of the admission agreements for each resident (4) to family/responsible party and email a copy to LPA via email by POC due 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


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 LIFE
FACILITY NUMBER: 198601265
VISIT DATE: 07/22/2023
NARRATIVE
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Operational Requirements: The facility has the appropriate fire clearance. The last Fire/Emergency Drill was conducted on 05/03/23. There is an outdoor activity area that is shaded and furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Jessica Monzon has a valid administrator certificate that expires on 05/31/24.
Personnel Records-Training: Staff has criminal record clearance. Staff have current CPR/first aid training and sufficient on-going training.
Client Rights-Information: Facility provides internet and telephone access for the clients in care.
Client Records-Incident Reports: Client files are kept in a secured location and have the following documents in their files – Regional Center Admission Agreement, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Medications for residents are securely stored in a locked cabinet. All medication observed during visit were properly labeled and in their original containers.
Incidental Medical & Dental: Staff designated to administer medication has the proper annual training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 2 staff interviews and 2 client interviews during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on 809D.

Exit interview was held and a copy of the report was provided to Assistant Administrator Roger Escorcia.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023
LIC809 (FAS) - (06/04)
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