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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600625
Report Date: 10/29/2024
Date Signed: 10/29/2024 04:03:14 PM

Document Has Been Signed on 10/29/2024 04:03 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/
DIRECTOR:		ORUNESAJO, AKINWALE VICTORFACILITY TYPE:
735
ADDRESS:411 GARDA AVENUETELEPHONE:
(818) 448-3012
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Staff Oluwagbemiro OdofinTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Staff Oluwagbemiro Odofin and the purpose of the visit was discussed. The following (12) (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan.

Operational Requirements:
  • A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
  • A fire clearance for four clients of which all (4) must be ambulatory is in place.

Physical Plant/Environment Safety:
  • The facility is vendorized through San Gabriel Pomona Regional Center . The Facility is a one story residential house consists of (4) client bedrooms, (2) bathrooms, living room, office, kitchen, dining room and an attached garage with laundry utilities
  • The physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies, sharps and toxic substances are inaccessible to clients.
  • Fire Alarms/CO2 detectors were inspected. Fire extinguishers Observed
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing
  • Sufficient staff observed to meet clients needs
  • Facility provides care and supervision for a total of (4) Clients.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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: 10/29/2024
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Personnel Records-Training:
  • Administrator on record is current.
  • Staff have criminal background clearance and training.
  • Five (5) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR and CPI training was observed.
Client Records-Incident Reports:
  • A total of Four (4) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.
Client Rights-Information
  • Client P&I Funds observed and safely stored
  • Internet source provided to clients in care
  • Complaint poster and Personal rights were observed posted.
Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar was reviewed
Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Sanitation practices and kitchen cleanliness was observed.
Incident Medical and Dental:
  • Four Client (4) centrally stored medications were reviewed. No errors observed
Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610D is in place. Last drill was completed on 9/5/24
Emergency Intervention:
  • There are no manual constraints in use.
  • Staff are trained to use CPI techniques.

Per California Code of Regulations, Title 22, NO deficiencies were cited. Visit completed using the CARE Tools Domains. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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