198602886-12-19-2023-28-AS-CWOG-CYP2NK-20231219163252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602886
Report Date: 12/19/2023
Date Signed: 12/19/2023 04:33:41 PM

Document Has Been Signed on 12/19/2023 04:33 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 @ VIRGINIA		FACILITY NUMBER:	198602886
ADMINISTRATOR:	DIANNE VILLANUEVA		FACILITY TYPE:	735
ADDRESS:	3010 E. VIRGINIA AVENUE		TELEPHONE:	(626) 430-7503
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:			TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to inspect the facility. LPA met with Lead Staff Vanessa Garcia and Eduardo Zamora and explained the reason of the visit. The facility is approved for serve for four (4) Developmentally Disabled Adults, AGE RANGE 18 THROUGH 59. 4 NON-AMBULATORY. APPROVED FOR DELAYED EGRESS ON EXTERIOR GATES ONLY. The facility is licensed as a 4I home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control Practice and Personal Hygiene Equipment (PPEs) were observed. Staff still practice hand washing, check clients and visitors temperature and mask wearing if needed. Staff also disinfected the facility every shift. The facility has an infection control plan and Covid-19 mitigation plan is in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in residential neighborhood area. The facility include: Living room, Dining room, kitchen, recreation room, four client bedrooms, three clients bathrooms, attached garage and staff office. Each client room has one bed, one chair, one drawer, required furniture and beddings and sufficient lighting and closet space. All three client bathrooms are clean, sanitary and in a good working condition. The hot water temperature tested in all three bathrooms are tested between 113 and 115.7 degrees F which are within the Title 22 regulation. All the appliances in the kitchen and living room are working properly. (See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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: 12/19/2023

NARRATIVE

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The knives and all sharp utensils are stored and locked in a lock box in kitchen cabinet. The cleaning supplies and all other chemicals are stored and locked in the hallway cabinet. The extra personal hygiene products are stored and locked in cabinet next to the recreation room and the staff office. The extra linen and towels are stored in the hallway cabinet and closet. The facility has a telephone service on the premises. The hallway light would be on during night time while the client can access the non-private bathroom. The carbon monoxide detectors were inspected and they are working well.

3. Operational Requirement: The facility is approved for 4 NON-AMBULATORY. APPROVED FOR DELAYED EGRESS ON EXTERIOR GATES ONLY. Currently all four clients are ambulatory. And the facility only has delayed egress on exterior gates only. The last fire drill was conducted on 10/6/23. The facility has a shaded area patio with table and chairs for client to utilize the outdoor activity. The facility also allow client to attend the community events if there's an opportunity and chance.

4. Staffing: The facility has sufficient staffing in the facility. LPA inspected NOC shift staff and he has the required facility planned emergency procedure training.

5. Personnel Records/Training: All the staff are over 18 years old, fingerprint cleared and associated with the facility. LPA inspected all three staff files and they all have the required documents which include: employee application, health screening, TB test result, required training hours and updated first aid and CPR certificate. The current administrator is Oscar Monzon and the administrator certificate expiration date on 7/9/24. The administrator also has the updated HIV and TB training certificate.

6. Client's Right/Information: Currently there's no client is required for postural support. The facility would serve internet with at least one internet access device for client to communicate with their day program or families.

7. Food Service: The facility has an ample supply of 2 days perishable and 7 days non perishable food in the facility. The facility has a freezer in the garage for additional food storage. All the food are stored properly in the facility. The facility provides three meals a day for client and snacks in between the day.

8. Client Records/Incident Reports: All the clients files are stored in the staff office in the garage. LPA inspected all four (4) clients files and they all have the required documents included: face sheet, admission agreement, functional capability assessment, individual program plan (IPP), physician report, TB test result, medication list and ambulatory status.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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 @ VIRGINIA	FACILITY NUMBER: 198602886
	VISIT DATE: 12/19/2023

NARRATIVE

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9. Health Related Services: The facility would provide transportation to client for their medical and dental appointments. All client's medication are centrally stored and locked in the kitchen cabinet. LPA inspected all four (4) clients medication. All the clients medication are accurate and up-to-dated and they all have 30 days supply of medication.

10. Incidental Medical Services: Currently there's no client in the facility is under restricted health condition plan and no client is with prohibited health condition.

11. Disaster Preparedness: The facility has an updated emergency disaster plan dated on 02/01/2023. The fire drill was conducted on 10/6/23 and the last disaster drill was conducted on 6/13/23. The facility also has two appropriate alternative shelter location.

12. Emergency Intervention: The facility does not use any restraint on clients but all staff are CPI trained with updated CPI Training certificate.

No deficiencies were observed during the visit.

Exit Interview Conducted and a copy of the report was provided to the Lead Staff.

(During the inspection, LPA was not able to interview the clients as they all were at the outings/community)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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