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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602886
Report Date: 01/07/2025
Date Signed: 01/07/2025 02:07:52 PM

Document Has Been Signed on 01/07/2025 02:07 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:INSIGHT FOR LIFE @ VIRGINIAFACILITY NUMBER:
198602886
ADMINISTRATOR/
DIRECTOR:		DIANNE VILLANUEVAFACILITY TYPE:
735
ADDRESS:3010 E. VIRGINIA AVENUETELEPHONE:
(626) 430-7503
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:12 AM
MET WITH:Conception Camarrillo- Lead DSPTIME VISIT/
INSPECTION COMPLETED:
11:47 AM
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Licensing Program Analyst (LPA) Vaid 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 Conception Camarillo, Eduardo Zamora arrived shortly after, 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 home vendored by San Gabriel Pomona Regional Center.

The following twelve (12) tool domains were observed and reviewed:

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 in residential neighborhood. The facility includes a 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 106.2, 105.3, 107.4 degrees F respectively, which are within the Title 22 regulation. All the appliances in the kitchen and living room are working properly. 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/Internet service on the premises. The hallway light would be on during nighttime while the client can access the non-private bathroom. The carbon monoxide detectors are interconnected and were inspected, and they are working well. Con't 809C......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSIGHT FOR LIFE @ VIRGINIA
FACILITY NUMBER: 198602886
VISIT DATE: 01/07/2025
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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. The facility has delayed egress on exterior gates only. The last fire drill was conducted on 01/03/25. The facility has a shaded area patio with table and chairs for client to utilize the outdoor activity. The facility also allows clients to attend the community events if there's opportunity.
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. 3-4 staff person 4 clients on AM and PM shifts, 2 staff persons for 4 clients during NOC shift.
5. Personnel Records/Training: All the staff are fingerprint cleared and associated with the facility. LPA inspected four staff files, and all have the required documents: 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 expires 7/9/26, assistant administrator certificate expires 05/09/2026. The administrator and assistant administrator both have 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 nonperishable 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 meals.
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: face sheet, admission agreement, functional capability assessment, individual program plan (IPP), physician report, TB test result, medication list and ambulatory status.
9. Health Related Services: The facility would provide transportation to client for their medical and dental appointments. All client's medication is centrally stored and locked in the kitchen cabinet. LPA inspected four (4) client’s medication. All the client’s medication are accurate and up-to-dated and they all have 30 days’ supply of medication.

Con't on 809C.......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSIGHT FOR LIFE @ VIRGINIA
FACILITY NUMBER: 198602886
VISIT DATE: 01/07/2025
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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 06/2024. The fire drill was conducted on 1/3/25 and the last disaster drill was conducted on 12/22/24. The facility has two appropriate alternative shelter locations.
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. Two clients were interviewed, other two were at day program.

Exit Interview Conducted and a copy of the report was provided to assistant administrator Eduardo Zamora.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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