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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801344
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:38:09 PM

Document Has Been Signed on 02/24/2022 02:38 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VICTORIA HOMEFACILITY NUMBER:
197801344
ADMINISTRATOR:MARIA ALVARADOFACILITY TYPE:
735
ADDRESS:14002 MANSA DRIVETELEPHONE:
(562) 921-0543
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 3DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrators/Licensees Maria and Jose AlvaradoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrators/Licensees Maria and Jose Alvarado and the purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (3) client records, (2) staff files, and (3) client medications. Currently the facility has (3) clients which are ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. The one story residential house consists of (2) client bedrooms, (1) client bathroom, (1) Isolation bedroom, living room, dining room, kitchen, staff family room, (2) staff bedrooms, (1) staff office, covered patio with table and chairs (back and front yards), and an attached garage/ laundry/ storage area. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#2 are equipped with two beds, a dresser, lamp, chair, overhead lightning and closet space. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in each client's bedrooms were observed. Fire alarms are interconnected and operational. Required postings observed. There is (1) fire places blocked off from use. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted. Copy of this report provided to Licensees Maria and Jose Alvarado.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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