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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881119
Report Date: 04/08/2021
Date Signed: 04/13/2021 07:57:16 AM

Document Has Been Signed on 04/13/2021 07:57 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VICTORIA FALLS HOME CAREFACILITY NUMBER:
331881119
ADMINISTRATOR:CLARK, ZINICAFACILITY TYPE:
740
ADDRESS:78554 PLEASANT DRIVETELEPHONE:
(760) 464-0236
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 0DATE:
04/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Zina ClarkTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA) Pauline Beschorner conducted an announced pre-licensing inspection to the facility via Microsoft Teams. LPA met with Licensee/Administrator Zina Clark and her son Theodore Stan.

Due to the license being a change of location, LPA met with Licensee/Administrator at the Scarborough Way address on 4/7/2021. LPA verified the furniture being moved into the facility was present. LPA observed 6 beds, 6 night stands, 6 chairs, 6 dressers and 6 lamps that will be moved into the new facility. LPA also observed a dining room table, dishes and food in the refrigerator and the pantry. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. LPA observed a completed first aid kit with a first aid manual. LPA also observed a charged fire extinguisher. In the backyard there was a chair with a table and an umbrella for the residents comfort outside which will also be moved to the new location.

On 4/8/2021 LPA met with Licensee/Administrator Zina Clark and her son Theodore Stan. During this pre-licensing inspection, LPA also conducted the Component III.

Currently the home is being used by the Mr. Stan. The home is a three bedroom, two bath home with a living room, dining room and kitchen. Per the approved fire clearance, the licensee is approved for 6 Non-ambulatory residents. The bathrooms were inspected to have grab bars and non-skid mats/flooring installed for resident safety. The water temperature was tested and measured at 110 degrees Fahrenheit. A centralized smoke detector was observed and operable. The facility has a carbon monoxide alarm installed and operable. LPA observed the locked closet in which the medications will be kept. LPA observed the knives and cleaners will be locked in the garage. The backyard has a large patio cover with chairs and a table for the residence comfort.

An exit interview was conducted and a copy of this report was reviewed and provided to Licensee/Administrator Zina Clark via email.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Pauline Beschorner
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2021
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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