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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600930
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:35:33 PM

Document Has Been Signed on 09/08/2022 03:35 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: 3DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Jocelyn Manalo, AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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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 Administrator Jocelyn Manalo 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 clients [ 2 non-ambulatory and 2 ambulatory]. It consists of 3 resident bedrooms, 1 staff room, 2 bathrooms, dining room, kitchen, living room, outdoor patio, enclosed porch/recreation room, and detached garage. Administrator certificate expires 11/29/2021.
The following were observed/inspected:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction.
  • COVID-19 Infection Control Practices and signs were observed in the entrance, common areas, hallways, and bathrooms.There is a screening station at the entrance of the facility to screen visitors.
  • Room #3 is designated as a COVID-19 isolation room if needed. Personal Protective Equipment (PPEs) was observed.
  • Two (2) client centrally stored resident medication records were reviewed. Medications are documented properly and given as prescribed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability.
  • The kitchen was inspected and a sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed. The kitchen stove back burners are not working.
  • A posted Emergency Disaster Plan was observed.
  • Facility has at least a 30-day supply of Personal Protective Equipment (PPEs).
  • Discarded appliances were observed in the front and backyard.
  • Wireless infrared smoke and carbon detectors were tested and are operational.
  • All staff have fingerprint clearances. Staff and resident files were not reviewed during today's visit.
***Facility has an Infection Control Plan that needs corrections. Licensee was instructed to submit the corrected Plan & the Monkey Pox Plan.
Per California Code of Regulations, Title 22, deficiencies are cited. See LIC 809D.
Exit interview was conducted with Administrator Jocelyn Manalo. A copy of the report/appeal rights were given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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Document Has Been Signed on 09/08/2022 03:35 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/08/2022 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTORIA RESIDENTIAL CARE HOMES
FACILITY NUMBER: 198600930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that two (2) A/C unit appliances and a washer was observed discarded in the front and back yard, and the two stove back burners are not operable; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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Administrator agreed to remove and discard the appliances in the front and back yards, and will repair and/or replace the stove. Submit picture proof evidence and repair invoice if applicable.
Type B
Section Cited
CCR
85064.3(d)
Administrator Recertification Requirements
To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the Administrator Certificate expired 11/29/2021, which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator stated that she has not completed all required courses for recertification.
POC Due Date: 10/06/2022
Plan of Correction
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Administrator agreed to submit proof of completed courses, and that he submitted all requirements to the recertification unit.
NOTE: If an extension is needed Administrator shall notify LPA by the POC due date [10/6/22].
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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