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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201178
Report Date: 07/27/2022
Date Signed: 07/27/2022 12:08:20 PM

Document Has Been Signed on 07/27/2022 12:08 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VICTORIA'S PLACE, INCFACILITY NUMBER:
079201178
ADMINISTRATOR:MENDOZA, ROLANDO GILFACILITY TYPE:
735
ADDRESS:2252 HAMLIN DRIVETELEPHONE:
(502) 544-3068
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 0DATE:
07/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rolando Gil Mendoza, Applicant
Maria Gonzalez, Applicant		TIME COMPLETED:
11:50 AM
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On 07/27/22 at 10:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an announced pre-licensing visit and met with applicants. LPA explained the purpose of the visit with applicants. LPA observed no clients at the facility during visit.

Facility has an approved fire clearance dated 05/11/22 for 6 clients. There are 3 bedrooms and 2 bathrooms. Posters including but not limited to Covid19 related posters, complaint poster, Personal Rights were observed. All bedrooms were observed furnished with a bed, dresser, closet, night stand, lamp and chair. Hallways and passageways were free of obstruction. There was sufficient lighting and furniture. The kitchen was observed clean and organized. There was sufficient supply of non-perishable foods observed. Plates, silver wares and glass wares were observed available. A copy of menu was posted on the bulletin board. Hot water measured at 115 F. There was a locked cabinet for medicine and resident files. Knives and other sharp objects and chemicals were kept in a locked drawer and cabinets in the kitchen & garage. There was sufficient supply of towels, sheets, blankets and hygiene products observed. PPEs, cleaning & paper supplies were observed stored in the garage. Smoke detector and carbon monoxide were tested and observed operational. First aid kit was complete. There were activity materials available. Facility has a washer and dryer installed in the garage. LPA observed a covered porch with chairs for use of clients. There were no bodies of water observed.

LPA observed no deficiencies during visit and that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.
Exit interview conducted and a copy of this report was provided to Applicants via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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