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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208904
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:11:23 PM

Document Has Been Signed on 10/06/2022 01:11 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:
107208904
ADMINISTRATOR:GITTI, JOSEPHFACILITY TYPE:
740
ADDRESS:5934 W LOCUST AVETELEPHONE:
(559) 960-3789
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 4DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Harmeen JhuttiTIME COMPLETED:
12:34 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. LPA met with and explained the reason for the visit with facility designee Harmeen Jhutti.

LPA toured the facility inside and out. Upon entry, LPA observed a visitor log/symptom screening, sanitizer and PPE. Infection Control and hand washing signs are posted throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap and paper towels at all sinks. LPA observed required food supply, paper products, 30-day PPE and resident medications. Cleaning/disinfecting products were locked. LPA reviewed quarantine/isolation procedures and updated visitor best practices. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed. Fire Extinguishers dated 9/2022. Administrator Certificate expiration 10/17/23.


No deficiencies cited during this inspection.

An exit interview was conducted. A copy of this report was left with Harmeen Jhutti whose signature confirms receipt of these documents.


LPA requested the following updated forms by 10/13/22: LIC 308, LIC 309, LIC 500, LIC 610E,
LIC 9020 and a copy of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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