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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803819
Report Date: 07/08/2021
Date Signed: 07/08/2021 10:46:18 AM

Document Has Been Signed on 07/08/2021 10:46 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VICTORIA MANORFACILITY NUMBER:
236803819
ADMINISTRATOR:REYES, VICTORIAFACILITY TYPE:
740
ADDRESS:419 GROVE STTELEPHONE:
(707) 456-1234
CITY:WILLITSSTATE: CAZIP CODE:
95490
CAPACITY: 6CENSUS: 4DATE:
07/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victoria Reyes AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analysts (LPAs) Shannan Hansen & Chris Arnhold conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Administrator Victoria Reyes. There were 4 residents present at the facility of a max capacity of 6.

All staff are temperature checked and logged each shift. LPAs toured the facility with Victoria Reyes. During our tour on 7/8/2021, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 2/2021 at the time of the visit. Smoke Detectors & 1 Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. There is a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Toxins and other cleaning supplies are stored in a locked cabinet in the laundry room.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility. Facility has PPE supply stored in closet adjacent to front door and in cabinet in garage. Residents’ medications are stored and locked in a cabinet in the front room/kitchen. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility.

In addition, facility has a designated area for visitors outside which are being allowed for scheduled visits. Residents have also available facetime and telephone calls when contacting with family members and others.
No citations issued at this time.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
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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