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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881252
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:58:30 PM

Document Has Been Signed on 08/09/2022 02:58 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VICTORIA ANN ELDERLY CARE, LLCFACILITY NUMBER:
331881252
ADMINISTRATOR:LARINA, IRINAFACILITY TYPE:
740
ADDRESS:3373 JUNE CTTELEPHONE:
(951) 241-1312
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 6DATE:
08/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Irina Larina, Applicant
Omar Canchola, Applicant		TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 2:00PM, LPA met with Applicants Irina Larina and Omar Canchola. An initial application to operate a Residential Care For the Elderly (RCFE) facility was received by the Central Applications Unit (CAU) on 09/24/2021 for a total capacity of six (6) residents, five (5) of which may be non-ambulatory and one (1) may be bedridden. Fire Clearance was granted on 06/24/2022 for a total of six (6) residents, of which five (5) may be non-ambulatory and one (1) may be bedridden. During today's visit, LPA Danielson observed the following:
Structure:
Facility was a single story house with four (4) resident bedrooms, one (1) resident bathroom, living room, family room, dining area and kitchen. There was an attached two (2) car garage in the front of the house. The facility also has a bedroom and bathroom designated for live in staff.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector.
Bathrooms:
The lone resident bathroom has a working toilet, wash basin and an adequate supply of paper towels, toilet paper, and soap. LPA verified bathroom water temperature was measured at 105 degrees Fahrenheit.
(CONTINUED ON LIC 812C)
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ANN ELDERLY CARE, LLC
FACILITY NUMBER: 331881252
VISIT DATE: 08/09/2022
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(CONTINUED FROM LIC809)
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in a locked room. Knives/sharp instruments were secured in a locked cabinet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents.
Living/Family room:
There was a living room with safe and adequate seating for all residents as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of additional linens and hygiene supplies were stored in a locked storage room.
Yards/Outside:
There was a patio with adequate shaded seating for all residents. All walkways were observed to be free of obstructions.
Garage:
Garage was free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, emergency exit plan, resident Personal Rights, and facility visitation policy were posted as required.
General items:
Two (2) fire extinguishers were charged and located in the dining room and office. Smoke alarms and carbon monoxide detectors were in working order. Resident records will be stored in a locked office. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring.

Component III was completed during today's visit and a hard copy was also provided for future reference.
Pre-licensing is complete and this facility has no deficiencies. Licensure will be granted based on final approved from CAU. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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