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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600930
Report Date: 09/05/2023
Date Signed: 09/05/2023 01:26:23 PM

Document Has Been Signed on 09/05/2023 01:26 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:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Estrella JoaquinTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to staff Estrella Joaquin. Administrator Jocelyn Manalo was explained the purpose of the visit telephonically. There are three (3) ambulatory developmentally disabled adults ages 18-59. The facility is licensed as a level 2 home vendored by San Gabriel/Pomona Regional Center. Twelve (12) Adult CARE tool domains were observed and reviewed.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility encourages hand washing and self symptom check of staff and visitors. The facility has an Infection Control Plan and COVID-19 mitigation plan.


Physical Plant/Environment Safety:
  • Facility is a single story home located in a residential area licensed for 4 [2 non-ambulatory & 2 ambulatory] residents. It consists of 4 bedrooms [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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. The facility has two (2) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.


See next page
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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: VICTORIA RESIDENTIAL CARE HOMES
FACILITY NUMBER: 198600930
VISIT DATE: 09/05/2023
NARRATIVE
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Operational Requirements:
  • The Plan of Operation is not being followed. Staff/Bedroom #4 was divided with a partition wall. The bedroom is now designated as a staff room and resident room. Per Fire Code, modifications to physical plant must be inspected and approved by West Covina Fire Department personnel. Per CCL, licensee shall adhere to the approved Plan of Operation and facility sketch. Citation was issued.
  • On 2/2/2022, fire clearance was approved for four (4) [2 ambulatory & 2 non-ambulatory] residents.
  • Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
  • Surety bond was reviewed and is current.

Staffing:
  • A total of three (3) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 11/29/2021. Per Licensee/Administrator documents were submitted to the recertification unit in late 2022, but has not received a current certificate. Technical Advisory issued.
  • Three (3) staff files were reviewed for criminal background clearance and training. Personnel records are incomplete. Staff (S2 & S3) do not have 1st Aid-CPR training. Staff (S3) does not have health/TB screenings. Citation was issued.
  • Staff records are disorganized. Per Licensee/Administrator, some personnel documents are off-site. However, they were not provided during today's visit.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Three (3) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, and medication administration records. Only partial Personal & Incidental (P & I) monies/records were at the facility for resident (R2).

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • There are physician orders for modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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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: VICTORIA RESIDENTIAL CARE HOMES
FACILITY NUMBER: 198600930
VISIT DATE: 09/05/2023
NARRATIVE
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan and COVID-19 vaccination cards on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. However, form LIC 610D is not current. Licensee is required to have an Emergency Disaster Plan/Disaster and Mass Casualty Plan. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. Citation was issued.
  • An emergency drill was conducted on 4/3/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, deficiencies were cited.


Exit interview conducted with staff Estrella Joaquin. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/05/2023 01:26 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2023 at 01:02 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: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S3) does not have a health screening/TB clearance on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator shall submit proof of S3's health screening/TB clearance.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S2 & S3) do not have current 1st Aid/CPR training on file; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator agreed to submit proof of 1st Aid/CPR training for staff (S2 & S3).
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: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/05/2023 01:26 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2023 at 01:02 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: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in thatAdministrator does not have the current LIC 610D "Emergency and Disaster Plan"; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator agreed to submit a copy of LIC 610D.
Type B
Section Cited
CCR
80022(j)
Plan of Operation
(j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 80061.
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 a partition wall has been added to bedroom #4 (staff room); it is now divided into 2 rooms (1 staff room & 1 resident room) without Fire department approval; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Licensee shall:
1. Contact local Fire Department about fire code regulation
2. Adhere to approved CCL Plan of Operation and fire clearance
3. Submit picture proof evidence the corrections have been made
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: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
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