<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209188
Report Date: 02/08/2024
Date Signed: 02/08/2024 03:05:49 PM


Document Has Been Signed on 02/08/2024 03:05 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:VICTORIA CARE HOME 2 INCFACILITY NUMBER:
107209188
ADMINISTRATOR:DAVOODI, NAHRINFACILITY TYPE:
740
ADDRESS:4770 W. OSWEGO AVETELEPHONE:
(559) 960-3789
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 4DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Harmeen JhuttiTIME COMPLETED:
01:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Harmeen Jhutti.

During this visit, LPA toured the facility inside & out. Resident bedrooms are found in good repair, contained required furnishings and lighting. The resident bathroom was clean and in good repair. LPA observed required hygiene items and grab bars. Towels, extra bedding, and linens were stored and available for use. Resident bathroom hot water measured 108 degrees. The kitchen was clean, in good repair with necessary items and appliances. LPA observed required food supply, PPE and paper products. Knives/sharps, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored in a locked cabinet. A First aid kit contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. LPA observed a self-releasing gate and windows have screens in good repair. There is a locked shed in the backyard which was found to store furniture. Smoke and Carbon Monoxide detectors were tested during the visit. The Fire extinguishers were serviced by Midstate Fire Co. on 1/4/24. LPA conducted resident and staff file reviews including medication audit. The Emergency Disaster Plan and Infection Control Plans were reviewed.

There were no citations during this inspection.



An exit interview was conducted and a copy of this report was provided to AD, whose signature confirms receipt

LPA requested the following updated forms faxed to CCLD by 2/16/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Emergency Disaster Plan (LIC610D), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402) Personnel Report (LIC 500). Client Roster (LIC 9020), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1