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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600625
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:20:54 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221206142805
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:
12/15/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Adejare Afolabi (Direct Support Professional) TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Adejare Afolabi (Direct Support Professional) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Client roster. Interviewed Staff #1 via telephone in the dining area, interviewed Staff #2 in the dining area and interviewed Client's #2 the dining area and attempted to interview Client #1 in the dining area.

In regards to the allegation: Facility staff handled resident in a rough manner. Interviews with Staff #1 and #2 indicate they did not handle a client in a rough manner nor have they witnessed other staff handle a client in a rough manner. Interview with Client #2 did not indicate staff handle them in a rough manner. Per allegation details, Regional Center and Law Enforcement investigated the alleged incident but was not able to obtain evidence to substantiate this allegation. Continue to LIC9099C.....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20221206142805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/15/2022
NARRATIVE
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Based on LPA's interviews and record review, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Adejare Afolabi and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2