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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206734
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:42:27 PM

Document Has Been Signed on 12/03/2021 02:42 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:VICTORIA'S CARE HOMEFACILITY NUMBER:
107206734
ADMINISTRATOR:JOSEPH GITTIFACILITY TYPE:
740
ADDRESS:6722 N. DELBERT AVE.TELEPHONE:
(559) 495-9859
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 6DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Joseph GittiTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Administrator Joseph Gitti. LPA entered through the central entry point where health screening was conducted. Visitor policy was observed at the front door.

Infection control procedures which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation, quarantine/isolation procedures, staffing, PPE and daily infection control procedures. All 6 residents and all staff are fully vaccinated. Covid Booster appointment has been scheduled.

LPA toured the facility inside and out. All required postings including to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Facility has multiple visitation areas available. LPA observed 30-day resident medication as well as PPE supply. Common and resident bathroom sinks are stocked with liquid soap and towels washing.


The following forms requested to be updated and submitted to LPA: LIC 308, 309 610, 500, 9020A, a copy of current Liability Insurance,

No deficiencies cited for Infection Control Annual Inspection.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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