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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209361
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:03:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2024 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20240820113800
FACILITY NAME:VICTORIA CARE HOME 2 INCFACILITY NUMBER:
107209361
ADMINISTRATOR:DAVOODI, NAHRINFACILITY TYPE:
740
ADDRESS:5056 W. ROBERTS AVETELEPHONE:
(559) 960-3789
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joseph GiTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility has a 'flip lock' on the inside of the main door of the home
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint investigation. LPA met with and explained the purpose of the visit and the element of the allegation with Licensee Joseph Gitti.

The Department investigated the allegation above. Based on observation and interview, it was determined that the "flip lock" had been placed on the front door to prevent wandering residents from leaving. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

An exit interview was conducted and the deficiency was cleared during this vsist. A copy of this report and Appeal Rights were discussed and left with AD, whose signature confirms receipt of these documents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20240820113800
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 INC
FACILITY NUMBER: 107209361
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2024
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents... (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night…. This requirement was not met as evidenced by
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DEFICIENCY CLEARED
Licensee immediately removed the "flip lock" from the door".
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Licensee did not ensure residents personal rights. A "flip lock" was placed on the front door to prevent residents from wandering out of the facility.

This poses a potential health and 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2