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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 12:09:07 PM

Document Has Been Signed on 07/27/2022 12:09 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rolando Gil Mendoza, Applicant
Maria Gonzalez, Applicant		TIME COMPLETED:
12:30 PM
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During the pre-licensing inspection on 07/27/22, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Component lll presentation with applicants.

During the Component lll presentation, LPA provided applicants information on how to operate the facility within Title 22 regulatory compliance as well as how to avoid common problem areas. Applicants confirmed understanding of regulations discussed.

Exit interview conducted and a copy of this report 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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