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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209188
Report Date: 01/25/2022
Date Signed: 01/25/2022 02:20:34 PM

Document Has Been Signed on 01/25/2022 02:20 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 CARE HOME 2 INCFACILITY NUMBER:
107209188
ADMINISTRATOR:DAVOODI, NAHRINFACILITY TYPE:
740
ADDRESS:4770 W. OSWEGO AVETELEPHONE:
(559) 960-3789
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 0DATE:
01/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Joseph GittiTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Shawna Doucette arrived to the facility announced to conduct the Pre licensing visit. LPA Shawna Doucette met with Licensee Joseph Gitti who granted LPA entry into the facility.

LPA toured facility. Common rooms have adequate furnishings and lighting. All of the resident bedrooms have all the required furnishings and adequate lighting. Hot water temperature in bathrooms measured at 119 degrees F. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen observed to have dishes, plates, utensils. Cleaning supplies are stored in a locked cabinet. Medications are locked in a medication cabinet. First aid kit contains all the required items. A fire extinguisher is present and has a service date of 10/05/2021. Smoke alarms and carbon monoxide were both functioning.

Outside of the facility toured. Exits open free of obstruction. Facility has delay egress on doors.

All required postings are posted or in process of being ordered. Facility phone number will be (559) 840-0624.

Component III was conducted during pre-licensing visit with Applicants.

I have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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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