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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603490
Report Date: 01/04/2022
Date Signed: 01/04/2022 11:55:19 AM

Document Has Been Signed on 01/04/2022 11:55 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 EBSH @ GIANOFACILITY NUMBER:
198603490
ADMINISTRATOR:FALATOONZADEH, MELLADFACILITY TYPE:
737
ADDRESS:601 GIANO AVETELEPHONE:
(626) 945-2709
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 0DATE:
01/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mellad Falatoon-Adminsitrator TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an announced visit to the facility for the purpose of pre-licensing evaluation. Also present were Benelida Glen , Resource Developer from San Gabriel Pomona Regional Center, Mellad Falatoonzadeh- Administrator and Oscar Monzon, licensee of the facility. An application was submitted to CCLD on 05/18/21, for Initial license for Adult Residential Facility- for Enhanced Behavioral Supports Home.

This is a one story home located in a residential neighborhood area which will be licensed as an Adult Residential Facility for Enhanced Behavioral Supports Home. The facility was toured. The following was observed: living and dining areas; 4 client bedrooms; two bathrooms, laundry room; kitchen; garage, front and back yards. There is one bed in each client bedroom. Each bed has all required linen and all bedrooms have required furniture, extra linens, and toiletry items. Bathrooms are clean and in good repair. Hot water temperature was tested between 108 and 110 degrees F . Posted & readily available for review in the top of the cabinet in the laundry room. Fire Extinguisher located near the linen cabinet mounted on wall. Laundry supplies are locked above the washer & dryer in the laundry room. Medications will be locked in a cabinet. Staff and client files will be stored and locked in the garage and inaccessible to clients. Cleaning solutions and toxins will be locked and stored under the sink and inaccessible to clients. . Kitchen is clean and in good repair and has dishes/eating utensils for client use, stove is operational. All the sharp utensils are stored and locked in kitchen cabinet. Food supply is adequate for both perishable and non perishable. There is one refrigerator in kitchen and one freezer in the garage for additional food storage. The smoke detectors and carbon monoxide detectors are combined and interconnected, and located in each bedroom and common are and they are all operational. A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in laundry room cabinet, available for staff use but inaccessible to clients.


SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 EBSH @ GIANO
FACILITY NUMBER: 198603490
VISIT DATE: 01/04/2022
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LPA observed the delayed egress and its operational. Yards are free of hazards and debris. Exits and passageways are free of obstructions. There is a patio table with chairs in the backyard and shaded activity space. The facility has board games, books, and other recreational materials for the client's use which is under the TV cabinet, commensurate with the plan of operation. Fire Clearance with bedroom# 2, 3 and 4 approved for non-ambulatory/bedridden and bedroom#1 approved for ambulatory and approval for delayed egress/secured perimeter on 10/8/21. For the Component III, it was conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC809 (FAS) - (06/04)
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