197610791-8-11-2025-31-AS-MAGN-DKFQS3-20250811122453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610791
Report Date: 08/11/2025
Date Signed: 08/11/2025 12:26:05 PM

Document Has Been Signed on 08/11/2025 12:26 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VICTORIA HOME 1		FACILITY NUMBER:	197610791
ADMINISTRATOR/ DIRECTOR:	OMOGBEHIN, ADETOLA		FACILITY TYPE:	735
ADDRESS:	10546 ALSKOG ST		TELEPHONE:	(818) 612-6019
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY: 4		CENSUS: 0	DATE:	08/11/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	Adetola Omogbehin		TIME VISIT/ INSPECTION COMPLETED:	12:45 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) Mariana Agban conducted a Pre-Licensing Inspection with the facility Licensee/Administrator Adetola Omogbehin. An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on March 10, 2025. A fire clearance was approved on April 15, 2025, for a maximum capacity of four (4) non-ambulatory Clients. The facility is a single-story home consisting of four (4) bedrooms, one (1) staff room, two (2) full non-ambulatory bathrooms, and one (1) 1/2 restroom. The smoke alarms and carbon monoxide detectors are battery-operated and functional. The facility has fire extinguishers that were serviced on February 3, 2025. The fire extinguishers were located in the living and dining area. A tour of the physical plant was initiated at 10:30 am, and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of four (4) clients. BEDROOMS: There are four (4) bedrooms designated for clients' use. All four bedrooms are designated for private use. All bedrooms are furnished with beds, dressers, and required bedding and linen. The bedrooms have sufficient closet space. LPA also observed the staff room that is next to the laundry area. BATHROOMS: There are two (2) bathrooms designated for clients' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 108.6 and 105.3 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. (Continue on 809C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

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 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORIA HOME 1	FACILITY NUMBER: 197610791
	VISIT DATE: 08/11/2025

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
26
27
28
29
30
31
32

COMMON AREAS: These included the living room and dining room, which were equipped with furniture, a television, two sofas, and a chair. LPA observed an office/ work station next to the living room.
The dining area has a dining table to accommodate four (4) clients. There were no visible immediate hazards. The auditory alarms on all exit doors were on and functional at the time of the visit.
Laundry Area: The washer/dryer appears to be in good condition. Laundry cabinets were locked, and thus laundry detergents are inaccessible to clients.
MEDICATION: The medication will be kept in a locked hallway cabinet.
SURROUNDING GROUNDS: The backyard of the facility has a patio and backyard furniture to accommodate the four (4) clients. The facility's backyard has sufficient yard space. LPA observed an exercise bike and a treadmill machine. There is no swimming pool or bodies of water. The side gate was checked to ensure it was clear of obstruction. LPA inspected the attached garage. No hazards observed. The garage is used for storage only.
Staff and resident files: Staff and resident files will be kept and maintained in a locked cabinet in the office/ work station area.

In addition to the Pre-Licensing inspection, a Component III PowerPoint presentation was also held.
Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to
be compliant and ready for licensure. CAB will be advised, and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3