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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608345
Report Date: 03/25/2022
Date Signed: 03/28/2022 03:59:20 PM

Document Has Been Signed on 03/28/2022 03:59 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VICTORY HOMEFACILITY NUMBER:
197608345
ADMINISTRATOR:ANDREW AKHPARIANFACILITY TYPE:
735
ADDRESS:6228 BABCOCK AVETELEPHONE:
(818) 585-0095
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 4CENSUS: 3DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Diana Gevorgyan, DesigneeTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Designee Diana Gevorgyan at 1:30 p.m., and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with the Designee at 1:26 p.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed the client bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Client restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Between 1:35 p.m. and 1:41 p.m., hot water temperatures measured between 113.1 and 115.2 degrees Fahrenheit in the private and common restroom(s).
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 113.5 degrees Fahrenheit at 2:30 p.m.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. Two (2) fire extinguisher was observed to be fully charged.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for client use. There was one (1) body of water noted. The garage is attached to the facility.

Continue on LIC809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VICTORY HOME
FACILITY NUMBER: 197608345
VISIT DATE: 03/25/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Designee regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

No deficiencies cited at this time. Exit interview conducted, and a copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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