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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602886
Report Date: 01/11/2023
Date Signed: 01/11/2023 03:20:11 PM

Document Has Been Signed on 01/11/2023 03:20 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 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:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Roger Escorcia - Facility RepresentativeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Vanessa Garcia (Registered Behavior Technician) and Eduardo Zamora (Lead Staff) and explained the reason for the visit. Roger Escorcia (Facility Representative) showed up shortly after. The facility is licensed to serve 4 non-ambulatory clients in the age range of 18 through 59. Facility is approved for delayed egress on exterior gates only. The facility is operating within the scope of its license.

A tour of the single-story facility included the living room, kitchen, dining area, 4 private client bedrooms, recreation room, 2 1/2 bathrooms, office, attached garage, front yard and backyard. LPA Mora conducted the tour with Eduardo, Vanessa and Roger, and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked in a kitchen cabinet. Cleaning chemicals are kept locked under the kitchen sink and hallway cabinet. The First Aid kit is kept locked in a hallway cabinet and it is fully stocked with all required items including a current manual. Medications are kept locked in a kitchen cabinet. Client and staff files are kept in the office. Clean towels and extra clean linen were observed in a hallway cabinet. Dining and living room have sufficient lighting and sitting area. All bedrooms have all required furniture, lighting, and bedding. The bathrooms were observed with shower mats and grab bars for non-ambulatory clients. The water temperature was tested in the all bathrooms and measured at 113.5, 114.2 and 113.2 degrees F, which is within the required 105-120 degrees F. Fire extinguishers were observed in the kitchen and hallway, and are fully charged. Facility has a wired fire system with carbon monoxide. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
Medications for all 4 clients were reviewed. Medications are documented properly and given as prescribed. Files for all 4 clients and 5 staff were reviewed. No deficiencies found with the files. LPA observed administrator certificate for Oscar Monzon - 6016665735 with expiration date 07/09/2024.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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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 @ VIRGINIA
FACILITY NUMBER: 198602886
VISIT DATE: 01/11/2023
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Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
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