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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601265
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:04:02 PM

Document Has Been Signed on 08/15/2024 03:04 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 LIFEFACILITY NUMBER:
198601265
ADMINISTRATOR/
DIRECTOR:		JESSICA MONZONFACILITY TYPE:
735
ADDRESS:606 N. LEAF AVETELEPHONE:
(626) 339-1016
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 3DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Luisa Perez - Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
03:18 PM
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Licensing Program Analyst(s) (LPA)s Mary Flores and Mayra Cota conducted an unannounced annual visit at the facility using the CARE inspection tool. LPAs met with Luisa Perez and explained the reason for the visit.

The facility is licensed to serve (4) ambulatory developmentally disabled adults between ages 18-59 years old.The facility is located in a residential area, and consist of a single home with 3 client bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry area, den, back yard, and an detached garage.

LPA conducted a tour with Eduardo Zamora - Corporation Representative and observed the following:
Living room/family room/den were observed clean with sufficient furniture. Two floor tiles in the den and two floor tile in the family room were observed cracked/broken in pieces. Kitchen area was observed clean, stove knobs were observed slightly removed and staff removed the knob to turn on the stove when asked staff stated it was broken and had to remove them to turn on the stove. Water was pushing back in the kitchen sink from the pipes due to washer currently being use. Laundry room was observed clean and in good repair. Medication and sharps were observed locked in a cabinet in the laundry area. Three (3) client bedrooms were observed in good repair, with sufficient lighting, bedding supplies, and the required furniture. Two bathrooms were observed clean, in good repair, and water temperature was tested between 110.5-112.8 degrees F., which is within the required 105-120 degrees F. Linen closet was observed. Cleaning/grooming supplies closet were observed locked. Interlace Smoke/Carbon monoxide detectors were tested are in good repair. Fire extinguisher was observed and last checked on 6/30/19. Backyard was observed clean, with a covered seating area. French door exiting to the backyard was observed stock and hard to open. No large bodies of water were observed. First aid kit was reviewed.

LPAs reviewed medication, files, and P&I money for 3 clients and 5 staff files.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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
FACILITY NUMBER: 198601265
VISIT DATE: 08/15/2024
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Infection Control Plan was observed. Emergency Disaster Plan (LIC 610D 10/03) was reviewed. Last fire drill was conducted on 7/15/24 and have been conducted every six months.

Administrator certificate was observed for Jessica Monzon #6020695735 exp. date: 10/31/24. HIV/TB training was taken on 11/28/22 by administrator.

LPAs interviewed 2 staff and 2 clients.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Roger Escorcia - Corporation Representative and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2024 03:04 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/15/2024 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INSIGHT FOR LIFE
FACILITY NUMBER: 198601265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in stove knobs were broken, water is backing up into kitchen sink, floor tiles were broken, and french door was not in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Administrator will contact a person to repair the listed items and will submit pictures and invoice of the repairs to the department by POC due date 8/22/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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