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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600930
Report Date: 09/22/2021
Date Signed: 09/22/2021 10:28:00 AM

Document Has Been Signed on 09/22/2021 10:28 AM - 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 RESIDENTIAL CARE HOMESFACILITY NUMBER:
198600930
ADMINISTRATOR:JOCELYN MANALOFACILITY TYPE:
735
ADDRESS:414 S ABELIAN AVETELEPHONE:
(626) 913-4707
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 3DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Evelyn Abrea, StaffTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Evelyn Abrea and explained the purpose of the visit. There are three (3) level 2 ambulatory developmentally disabled clients ages 18-59 in the home. The facility is a single story home located in a residential neighborhood that is licensed for 4 ambulatory and 2 non-ambulatory clients. It consists of 3 resident bedrooms, 1 staff room, 2 bathrooms, dining room, kitchen, living room, outdoor patio, enclosed porch room, and detached garage. The last fire drill was conducted on 5/3/2021.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected.
  • COVID-19 Infection Control Practices and signs were observed in the entrance, common areas, hallways, and bathrooms.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart.
  • Facility has one (1) designated isolation room.
  • Three (3) centrally stored resident medication records were reviewed.
  • Due to client's disability and behaviors none of the clients in care wear masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.

No deficiencies cited today.

Exit interview was conducted with staff Evelyn Abrea. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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