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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801225
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:46:45 PM

Document Has Been Signed on 01/07/2025 01:46 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VICTORIA'S PLACEFACILITY NUMBER:
496801225
ADMINISTRATOR/
DIRECTOR:
MEJIA-CHISTIAKOFF,CONCHITAFACILITY TYPE:
740
ADDRESS:2300 DONAHUE AVE.TELEPHONE:
(707) 843-0341
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 6DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:04 PM
MET WITH:Orr Chistiakoff (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Licensee, Orr Chistiakoff. Annual fees are current.

LPA/staff initiated a tour of the facility at 12:10 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 115.2 and 112.3 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cleaning supplies stored under kitchen sink and in outside laundry room were inaccessible to residents in care. Knives and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected May 2024. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Exit doors have auditory alert system and were functional at time of visit. Medications and medication records were reviewed. Required postings were observed.

LPA initiated file review at 12:30 pm. Two staff files and six resident files were reviewed. Staff have required CPR/1st aid and 20 hours annual training hours completed. Residents care plans and medical assessments were updated within the last 12 months. Administrator Certificate for Administrator, Medardo A Galvez, 6058961740, expires on 4/12/25.

Licensee will submit updates of the following documents by 1/17/25: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Liability Insurance Certificate.
No deficiencies cited during today's visit. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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