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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208792
Report Date: 06/28/2022
Date Signed: 07/06/2022 09:12:04 AM

Document Has Been Signed on 07/06/2022 09:12 AM - 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:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joseph GittiTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Infection Control Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Joseph Gitti. LPA entered through the central entry point where Visitor sign in, hand sanitizer and infection control postings were observed.

Infection control procedures which were observed and/or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation requirements, quarantine/isolation procedures, staffing, PPE and daily infection control procedures.

LPA toured the facility inside and out. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed resident medication and 30-day supply of PPE. LPA observed cleaning and disinfecting products. LPA observed required supply of food, paper products and emergency supplies.


No deficiencies cited during this inspection.

A copy of this report was emailed to nahrindavoodi@yahoo.com and an exit interview was conducted.

LPA requested the following updated forms by 7/7/22: LIC 308, LIC 309, LIC 500, LIC 610E, LIC 9020, Copy of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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