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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208792
Report Date: 06/22/2021
Date Signed: 07/30/2021 03:38:16 PM

Document Has Been Signed on 07/30/2021 03:38 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:
107208792
ADMINISTRATOR:GITTI, JOSEPHFACILITY TYPE:
740
ADDRESS:5161 W PALO ALTOTELEPHONE:
(559) 960-3789
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 5DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Nahrin TIME COMPLETED:
12:00 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 Administrator, Nahrin Davoodi and completed the Covid Contact questionnaire. Upon entry, LPA observed the Visitor sign in, sanitizer and available masks.

Facility Mitigation plan has been submitted to CCL. Infection control procedures described in the plan which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, and daily infection control procedures.

LPA toured the facility inside and out. Required postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were all observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed 30-day resident medication supply. Common and resident bathroom sinks are well stocked with liquid soap and paper towels for hand washing.

Resident, Visitor and Staff screening logs will be updated and reinstated. Administrator has requested a supply of PPE.

Through LPA’s observations, documentation review and interview with Administrator, the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2021
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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