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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208904
Report Date: 10/06/2023
Date Signed: 10/06/2023 12:53:14 PM

Document Has Been Signed on 10/06/2023 12:53 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:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Harmeen JhuttiTIME COMPLETED:
01:14 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 Facility Designee/Administrator (AD) Harmeen Jhutti.

During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring 110 degrees F. 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 and cleaning/disinfecting supplies are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contains required items. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the home including outdoors. Fire Extinguishers dated 1/16/23. Smoke and Carbon Monoxide detectors are present and in working order. LPA conducted resident and staff file reviews, interviews and a medication audit. Administrator certification expires 10/17/23 and re-certification is in process. Emergency Disaster Plan and Infection Control Plan were reviewed during this visit.

There were no citations issued during this inspection.

An exit interview was conducted and a copy of this report was provided to AD whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 10/13/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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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