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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209188
Report Date: 12/19/2024
Date Signed: 12/19/2024 01:27:44 PM

Document Has Been Signed on 12/19/2024 01:27 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/
DIRECTOR:		DAVOODI, NAHRINFACILITY TYPE:
740
ADDRESS:4770 W. OSWEGO AVETELEPHONE:
(559) 960-3789
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: DATE:
12/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Joseph GittiTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Joseph Gitti. This Case Management visit was held at 6722 N. Delbert Fresno, 93722. This facility is also operated by AD.

The purpose of this Case Management is to follow up on an incident which occurred on 12/13/24 resulting in Resident (R1) receiving medication at the wrong time. All reporting, including submission of a Special incident Report (SIR) to CCL as required.

Deficiency has been cited in accordance with California Code of Regulations on the attached LIC 809-D in the area of: Personnel Requirements – General

An exit interview was conducted. The deficiency was cleared during the visit. The Plan of correction has already been conducted and implemented. A signed copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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Document Has Been Signed on 12/19/2024 01:27 PM - It Cannot Be Edited


Created By: Katie Brown On 12/19/2024 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VICTORIA CARE HOME 2 INC
FACILITY NUMBER: 107209188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2024
Section Cited
CCR
87411(d)(4)

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87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following… (4) Knowledge required to safely assist with prescribed medications which are self-administered.

This requirement was not met as evidenced by:
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DEFICIENCY CLEARED
AD has provided training to the staff member. The medication pass procedure has been reviewed and updated. All staff are trained or revised procedure.
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Licensee did not ensure a staff member Knowledge required to safely assist with prescribed medications which are self-administered. R1 was given her PM medications in the morning instead of AM medications.

This poses a potential health & safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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