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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600625
Report Date: 10/20/2023
Date Signed: 10/20/2023 12:50:09 PM

Document Has Been Signed on 10/20/2023 12:50 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:VICTORIOUS RESIDENTIAL HOMEFACILITY NUMBER:
198600625
ADMINISTRATOR:ORUNESAJO, AKINWALE VICTORFACILITY TYPE:
735
ADDRESS:411 GARDA AVENUETELEPHONE:
(818) 448-3012
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 4DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Victor OrunesajoTIME COMPLETED:
01:10 PM
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On 10/20/23 at 9:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Victorious Residential Home. Upon arrival LPA observed there was no one home and LPA contacted the via phone. The administrator Victor Orunesajo arrived at 10:33 a.m., and LPA explained the reason for the visit. This home is licensed to serve (4) Developmentally Disabled Clients, ages 18 through 59, ambulatory only. The is a level 4G home and vendorized through San Gabriel Pomona Regional Center. There were (0) clients in care during the time of this visit, all (4) clients were at the day program. The last emergency disaster/fire drill was conducted on 10/06/23. The Administrator Certificate expired on 06/11/2023 #6002604735. Due to CCLD website undergoing maintenance, LPA could not verify administrator certificate. The administrator showed LPA a copy of hours and submission dated 2/2023. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (4) client files, medications, and medication administration records for (4) clients and P&I.

This home contains 4 bedrooms, 2 bathrooms, living room, office, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, water faucet, grab bar, and bathmat. The temperature measured at 106.7*F-107.7*F. The smoke detectors were battery operated and tested and observed to be working properly. The carbon monoxide detector was located in the living room, tested, and functioning properly. There were (2) fire extinguishers located in the dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The cleaning agents, toxins with knives were secured and locked in the hallway cabinet. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VICTORIOUS RESIDENTIAL HOME
FACILITY NUMBER: 198600625
VISIT DATE: 10/20/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, Food, bottled water, toiletries, and personal care supplies.

The Living room contained a non-working fireplace contained a covered screen so that it was inaccessible to the clients.

Exit interview conducted with Victor Orunesajo, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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