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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206933
Report Date: 12/27/2021
Date Signed: 12/27/2021 12:58:55 PM

Document Has Been Signed on 12/27/2021 12:58 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:
107206933
ADMINISTRATOR:GITTI, JOSEPHFACILITY TYPE:
740
ADDRESS:6736 N WESTERN AVETELEPHONE:
(408) 482-6166
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 6DATE:
12/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Suaan San JuanTIME COMPLETED:
01:00 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 Designee/Administrator Susan San Juan. LPA entered through the central entry point where health screening was conducted. Visitor policy, PPE and sanitizer was observed in the entryway.

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 live in staff are fully vaccinated, including boosters.

LPA toured the facility inside and out. LPA observed locked/inaccessible pool. Required postings as well as Covid-19 and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Facility has designated 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 by 1/5/2022: 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: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2021
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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