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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209080
Report Date: 09/06/2022
Date Signed: 09/06/2022 12:58:21 PM


Document Has Been Signed on 09/06/2022 12:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:VICTORIA'S CARE HOMEFACILITY NUMBER:
107209080
ADMINISTRATOR:GITTI, JOSEPHFACILITY TYPE:
740
ADDRESS:5288 N. ROSALIA AVETELEPHONE:
(559) 960-3789
CITY:FRESNOSTATE: CAZIP CODE:
93723
CAPACITY:6CENSUS: 4DATE:
09/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Nahrin Davoodi, AdministratorTIME COMPLETED:
01:15 PM
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On 9/6/22, Licensing Program Analysts (LPAs), V. Gorban and A. Walton conducted an unannounced Annual Required Infection Control Inspection. LPAs observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. All staff utilize main entrance with COVID-19 infection protocols prior to starting shift. Mitigation plan was received and approved by Department.

LPAs toured the facility with Nahrin Davoodi, facility Administrator. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. LPAs observed a 30 day supply of PPE and resident medications. Several residents restrooms in toured and observed to have adequate soap and paper products available.

Through LPA's observation of documentation and interview with Administrator, the required infection control practices are found to be in compliance. No deficiencies were observed.

Exit interview was conducted and report signed. A copy of this report provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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