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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603226
Report Date: 09/09/2023
Date Signed: 09/15/2023 11:45:25 AM

Document Has Been Signed on 09/15/2023 11:45 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
GREATER LA AC/SC, 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: 2DATE:
09/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Roger Escorcia - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Roger Escorcia (Administrator) explained the purpose for the visit. The facility is licensed to serve 2 Non-Ambulatory clients ages 18-59 years old.

The facility is a single-story home located in a residential area in La Puente, Ca. A tour of the facility includes: 1 den, living room, dining area, kitchen, 2 client bedrooms, 2 bathrooms, sensory/activity room, administrator office, staff office area, laundry closet, attached garage, front and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: There are 2 client bedrooms, 2 bathrooms, 1 den, living room, dining area, kitchen, sensory/activity room, administrator office, staff office area, laundry closet, attached garage, front and back yard. Client bedrooms had the required furniture for comfort and safety and had sufficient lighting. All outdoor passages were free of obstruction. Bathrooms were clean, toilets and water faucets worked properly. Water temperature was measured in both client bathrooms and were within the required range of 105 – 120 Degrees F. Client bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are securely stored and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. Facility has sprinkler system and operating delayed egress. The fire extinguishers were observed to be fully charged.

(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2023
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 @3RD AVE
FACILITY NUMBER: 198603226
VISIT DATE: 09/09/2023
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Operational Requirements: The facility has the appropriate fire clearance. The last Fire/Emergency Drill was conducted on 09/04/23. There is an outdoor activity area that is shaded and furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Roger Escorcia certificate expired on 05/27/23 but showed proof of pending renewal with all documents, received by CCL on 06/06/23.
Personnel Records-Training: Staff has criminal record clearance. Staff have current CPR/first aid & CPI training along with sufficient on-going training.
Client Rights-Information: Facility provides internet and telephone access for the clients in care. There are no postural supports used by the clients in care.
Client Records-Incident Reports: Client files are maintained and are electronically secured, files have the following documents – Admission Agreement, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan, Emergency Intervention Plan and Behavioral Support Plan (within each clients Functional Behavior Assessment).
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Medications for residents are securely stored in a locked closet. All medication observed during visit were properly labeled and in their original containers.
Incidental Medical & Dental: Staff designated to administer medication has the proper annual training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency Intervention: Residents at this facility have not needed the use of restraints or the use de-escalation techniques since date of admission, however, staff do have proper training and facility maintains a restraint long and incident report log in the case that they do need use those techniques.

LPA conducted 1 staff interview and 0 client interviews during today’s visit. Clients were away at day program during visit.
LPA reviewed 3 staff files and 2 client files during visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.
Exit interview was held and a copy of the report was provided to Administrator Roger Escorcia
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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