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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206933
Report Date: 01/03/2024
Date Signed: 01/03/2024 02:48:00 PM

Document Has Been Signed on 01/03/2024 02:48 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:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Harmeen JhuttiTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Asst. Administrator (AD) Harmeen Jhutti

During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. The resident bathroom was clean, LPA observed required items and the hot water temperature measured 116 degrees. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPA observed a self-releasing gate and windows have screens in good repair. Smoke and Carbon Monoxide detectors present and in working order. Fire extinguisher date 1/13/23. LPA conducted resident and staff file reviews including medication audit and interviews.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D.
An Immediate Civil Penalty is being assessed on the attached LIC421IM.

An exit interview was conducted and Plan of Correction was developed and cleared during inspection. A copy of this report and Appeal Rights were discussed and signed by AD. The reports were emailed to joegitti@aol.com and harmeenjhutti@gmail.com.

LPA requested the following updated forms faxed to CCLD by 1/10/24: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610E, Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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Document Has Been Signed on 01/03/2024 02:48 PM - It Cannot Be Edited


Created By: Katie Brown On 01/03/2024 at 02:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VICTORIA'S CARE HOME
FACILITY NUMBER: 107206933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

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 iwhich poses an immediate health, safety or personal rights risk to persons in care. LPA observed that the pool gate was not locked. Residents, including those with Dementia have access to the pool. There are 2 gate in which the pool can be accessed.
POC Due Date: 01/03/2024
Plan of Correction
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During the inspection, pad locks were placed on both gates that access the pool from the house.
Deficiency cleared during this inspection.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


LIC809 (FAS) - (06/04)
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