107209569-7-9-2025-24-AS-KBRN-DJERU9-20250709131935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209569
Report Date: 07/09/2025
Date Signed: 07/09/2025 01:23:02 PM

Document Has Been Signed on 07/09/2025 01:23 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		FACILITY NUMBER:	107209569
ADMINISTRATOR/ DIRECTOR:	DAVOODI, NAHRIN		FACILITY TYPE:	740
ADDRESS:	6706 N. MCCAFFREY AVE		TELEPHONE:	(559) 960-3789
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY: 6		CENSUS: 0	DATE:	07/09/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Nahrin Davoodi		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Administrator (AD) Nahrin Davoodi and Joseph Gitti. LPA began the tour by entering through the front door of the 6-bedroom, 2-bathroom home. This facility has fire clearance for 5 non-ambulatory, 1 bedridden residents. 1 room is designated for care staff. Required postings were observed hung in the entry way. Common areas throughout the home were well lit with functioning ceiling fans, clear walkways and flooring intact. LPA observed required supply of cleaning, disinfecting and paper products properly stored. LPA observed resident bedroom to find required furniture, bed linens, lighting, towels and personal hygiene/grooming products. The bathrooms are clean, with grab bars and skid resistant mats in good repair with faucets delivering hot water at 110 degrees F. Smoke and Carbon Monoxide detectors were tested and found to be in working order. The Fire Extinguishers were purchased 2/10/2025. The kitchen was observed to have a supply of dishes, plates, utensils, and cooking items. Cleaning supplies, chemicals, sharps and knives are locked and stored as required. Appliances were found to be in working order. LPA observed food supply, including separate emergency food, water and supplies. Resident medications will be stored in a locking kitchen cabinet. The First aid kit contained the required items. Doors and passageways are unobstructed throughout the inside of the home. See LIC809C for continuation of this report

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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	FACILITY NUMBER: 107209569
	VISIT DATE: 07/09/2025

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Outside of the facility was toured. There is a covered seating area, and a self-releasing gate found to be working properly. Walkways in front and backyards are clear. The facility phone number is (559) 293-4749

Emergency Disaster and Infection Control Plans were reviewed, and COMP III was conducted during this visit with AD. An exit interview was conducted, and a copy of this report was signed and emailed to AD.

The applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento
for final review prior to license being issued.

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC809 (FAS) - (06/04)

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