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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804416
Report Date: 05/09/2022
Date Signed: 05/09/2022 12:12:53 PM

Document Has Been Signed on 05/09/2022 12:12 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VILLA VICTORIA CARE HOMEFACILITY NUMBER:
370804416
ADMINISTRATOR:LABRADOR, VICTORIA N.FACILITY TYPE:
740
ADDRESS:1312 LEAF TERRACETELEPHONE:
(619) 266-2356
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 5DATE:
05/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Victoria Labrador, LicenseeTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit. LPA Lopez identified herself and was granted entry by Fe Oca, Caregiver. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Victoria Labrador, Licensee.

On May 6, 2022, the facility self-reported a resident death regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing. This visit was conducted on to follow-up with the death report.

During today’s visit, LPA briefly toured the facility, conducted staff interviews, and requested and obtained relevant records. This case management visit requires further follow-up and a copy of the resident’s death certificate was requested upon receipt. No deficiencies were cited during today’s visit.

An exit interview was conducted with Licensee Victoria Labrador and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 01/16) were provided at the conclusion of the visit. The signature on the report serves as confirmation of receipt for the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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