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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602886
Report Date: 01/27/2022
Date Signed: 02/09/2022 09:33:17 AM

Document Has Been Signed on 02/09/2022 09:33 AM - 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 LIFE @ VIRGINIAFACILITY NUMBER:
198602886
ADMINISTRATOR:DIANNE VILLANUEVAFACILITY TYPE:
735
ADDRESS:3010 E. VIRGINIA AVENUETELEPHONE:
(626) 430-7503
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Diane VillanuevaTIME COMPLETED:
05:10 PM
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1/27/2022 Licensing Program Analyst (LPA) conducted an unannounced annual inspection visit. LPA met with Administrator, Diane Villanueva and stated the purpose of the visit. LPA conducted annual using the Infection Control Domain.

This home licensed to serve Developmentally Disabled individuals ages 18 to 59. The (4) Clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center. (1) one of the clients (Client #1/C-1) is over the age of 59 and has been granted an age exemption by DSS. Facility has been granted fire clearance on 9/21/2018 by West Covina Fire Department for delayed egress on exterior gates only and all bedrooms approved for non-ambulatory. Licensing annual fees are current.

This facility is a single story house with a living room, kitchen, dining area, activity room, 4 private client bedrooms, recreation room, 2 1/2 bathrooms and an attached car garage.

LPA toured the facility property with Administrator. All staff were observed to be wearing mask upon entrance and during visit. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The kitchen was inspected. LPA observed the kitchen equipment's to be clean and in working condition. LPA observed the food supply stored at the facility. There was a sufficient quantity of the perishable for 2 days and non-perishable food supplies for 7 days for all clients. Cleaning chemicals are locked and inaccessible to clients. Centrally stored medicines are kept locked in the kitchen cabinet. Each bedroom is equipped with the proper furniture and linen. Bathrooms had non-skid mats and grab bars. Passageways are clean and free of debris. No weapons, ammunition or bodies of water on premises. LPA observed COVID19 informational and symptom posters by front door and throughout facility. There is hand sanitizer available throughout facility.

CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 @ VIRGINIA
FACILITY NUMBER: 198602886
VISIT DATE: 01/27/2022
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The following deficiencies were observed:
  • At 2:35 p.m. LPA observed cabinet and storage safe where sharps are located was unlocked and
accessible to clients in care.
  • At 2:50 p.m. LPA observed water temperature in common bathroom at 100 degrees Fahrenheit


Deficiencies cited, refer to 809-D. Exit interview conducted, a copy of this report and appeal rights provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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Document Has Been Signed on 02/09/2022 09:33 AM - It Cannot Be Edited


Created By: Nina Galarza On 01/27/2022 at 04:20 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: INSIGHT FOR LIFE @ VIRGINIA
FACILITY NUMBER: 198602886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings 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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At 2:35 p.m. LPA observed cabinet and storage safe where sharps are located was unlocked and
accessible to clients in care. Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2022
Plan of Correction
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All sharps were secured, locked and made inaccessible to clients at time of visit. Administrator will provide proof of signed staff training and material on importance of securing items that could pose a danger if readily available to clients.
Type A
Section Cited
CCR
80088(e)(1)
80088 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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At 2:50 p.m. LPA observed water temperature in common bathroom at 100 degrees Fahrenheit. Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2022
Plan of Correction
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Administrator will provide proof of hourly water temperature log.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
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