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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600930
Report Date: 02/10/2022
Date Signed: 02/10/2022 12:34:28 PM

Document Has Been Signed on 02/10/2022 12:34 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 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: 4CENSUS: 2DATE:
02/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Jocelyn Manalo, AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) N. Galarza conducted a case management visit to inspect the facility for a capacity decrease from six (6) [4 ambulatory & 2 non-ambulatory] to four (4) [2 ambulatory & 2 non-ambulatory] clients. The facility is licensed to serve developmentally disabled clients (ages 18 through 59 years). The fire safety inspection for a capacity decrease was granted by Inspector R. Beihl of the West Covina Fire Department on 2/2/2022.

A tour of the facility included Bedroom #1 - (non-ambulatory; double), Bedroom #2 – private, Bedroom #3 – private, Room #4 is a staff room, kitchen, living room, dining room, activity room, backyard, garage, and two (2) bathrooms were observed. The last Annual/Required visit was conducted on 9/22/2022.

LPA observed 2 clients living in the home. Bedroom # 3 still has 2 beds. Administrator agreed to send pictures showing the removal of the extra bed. Bedroom #1 had a new sliding door installed for the fire clearance, and the old sliding door was observed in the backyard. Administrator will submit picture proof the debris was removed from the backyard.

A new license will be generated and mailed once the capacity decrease has been approved by Manager.


An exit interview was conducted with Administrator Jocelyn Manalo. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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