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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603226
Report Date: 08/18/2022
Date Signed: 08/18/2022 11:21:06 AM

Document Has Been Signed on 08/18/2022 11:21 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 @3RD AVEFACILITY NUMBER:
198603226
ADMINISTRATOR:ESCORCIA, ROGERFACILITY TYPE:
737
ADDRESS:549 S. 3RD AVETELEPHONE:
(626) 945-2709
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 2CENSUS: 1DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Roger Escorcia - Administrator TIME COMPLETED:
11:30 AM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, medication and food review. LPA Flores met with Roger Escorcia Administrator and explained the reason for the visit.

The facility is licensed to served 2 non-ambulatory adults within the age range of 18 through 59 years old. The home is located in a residential area and consist of (2) client bedrooms, (2) bathrooms, kitchen, dining room, living room, office room, recreation room, laundry room, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. The home has a sprinkler system and operating delayed egress. There is currently (1) client residing at the facility.

LPA Flores tour the facility with Roger Escorcia Administrator and observed the following:
Facility is in good repair and free of debris. Knives are kept under a magnetic lock in a drawer next to the stove and cleaning supplies are kept under a magnetic lock under the kitchen's sink. Facility has sufficient food supplies sufficient for at least 2 days worth of perishables and 7 days of non-perishables. Facility maintains a separate emergency food supply in the kitchen. Clients' rooms have sufficient lighting, required bedding and furniture. Both bathrooms were observed to have grab bars, water temperature was tested as follow: Bathroom #1(B1) tested at 114.0 degrees F., and bathroom #2(B2) tested at 109.9 degrees F., which is within the required temperature of 105-120 degrees F. LPA reviewed medication and file for client #1 and 2 staff files. Administrator's certificate was observed #6002729735 exp: 5/27/23.
Facility has sufficient PPE supplies for more than 30 days. Facility is following infection control recommendations. N95 Fit testing has not been done with staff, administrator will reach out to resources and schedule fit testing.
Per Title 22 Regulations no deficiencies were noted during this visit. Exit interview was conducted with Roger Escorcia administrator and a copy of this report will be email to administrator due to technical difficulties.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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