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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881252
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:49:32 PM

Document Has Been Signed on 10/29/2024 12:49 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VICTORIA ANN ELDERLY CARE, LLCFACILITY NUMBER:
331881252
ADMINISTRATOR/
DIRECTOR:		LARINA, IRINAFACILITY TYPE:
740
ADDRESS:3373 JUNE CTTELEPHONE:
(951) 241-1312
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 5DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Omar Canchola, ManagerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Manager, Omar Canchola. The LPA informed the Manager of the purpose for the visit. The inspection included the following:

Physical Plant: The facility consists of four (4) resident bedrooms, two (2) bathrooms, one (1) storage room, a kitchen and dinning areas, a living room area, a garage/staff lounge area, and a sun room and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Manager Canchola, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The carbon monoxide and smoke detectors were tested by the Manager and were observed to be in operating condition. The home was kept clean, organized and free of any odors.

Food Service: There is a minimum of two (2) days supply of perishable foods and one (1) week's supply of non-perishable foods available. Sufficient dinning supplies were available for residents in care. A variety of food was available and stored in a safe and healthful manner.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care and medication training was observed to be complete. Postural support, restricted health conditions and hospice care training was observed on file. Resident files had admission agreements, medical assessments, appraisal/needs and services plans, and other required records on file. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for six (6) residents and there is currently one (1) residents in care
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VICTORIA ANN ELDERLY CARE, LLC
FACILITY NUMBER: 331881252
VISIT DATE: 10/29/2024
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receiving hospice services. There is a disaster and mass casualty plan in place. Proof of emergency drills were observed on file. All records were observed to be well organized and safely secured. According to Manager Canchola, the LLC is active. The LPA observed current liability insurance on file.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, appropriately labeled and inaccessible to unauthorized individuals.

Manager Canchola agreed to provide the LPA with a copy of the current liability insurance, staff schedule, resident roster, and designation of facility responsibility.

An exit interview was conducted with Manager Canchola, in which this report was reviewed and a copy was provided. No citations were issued during this visit.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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