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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600930
Report Date: 09/13/2024
Date Signed: 09/13/2024 12:44:02 PM

Document Has Been Signed on 09/13/2024 12:44 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/
DIRECTOR:		JOCELYN MANALOFACILITY TYPE:
735
ADDRESS:414 S ABELIAN AVETELEPHONE:
(626) 913-4707
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Estrella Joaquin, DSPTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to DSP Estrella Joaquin. Administrator was explained the purpose of the visit telephonically. The facility serves developmentally disabled residents under age 59. The facility is licensed as a level 4G Adult Residential Facility (ARF) vendored by San Gabriel/Pomona Regional Center. The facility is a single story home located in a residential neighborhood consisting of 4 bedrooms, kitchen, living room, dining room, activity room, backyard, garage, and two (2) bathrooms were observed. The following 12 (CARE) tool domains were utilized during the inspection

Infection Control: The facility has an Infection Control Plan in place.

Physical Plant/Environment Safety: 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 (2) fully charged fire extinguishers. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients. Hot water temperature readings did not measure between the required 105 - 120 degrees Fahrenheit; readings were 129.7- 129.9 DF. Client (C1 & C2's) beds did not have mattress pads.

Operational Requirements: Fire clearance is approved for two (2) ambulatory and (2) non-ambulatory clients. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. The Surety Bond is current. P & I money is not kept separate from other clients in care and some P & I ledgers did not have balance amounts listed.



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

Personnel Records/Staff Training: Two (2) staff files were reviewed. Criminal background clearance, TB clearance, in-service training, 1st Aid/CPR training, and health screening. Administrator file was not available for review.

Administrator certificate expired 11/29/2023. Ms. Manalo sent recertification documents late (not 90 days prior to expiration) until 5/28/2024. Certification is currently pending.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 09/13/2024 12:44 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/13/2024 at 11:54 AM
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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

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 clients (C1 & C2's) beds did not have mattress pads, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Administrator shall submit picture proof evidence that C1 & C2's bed have mattress pads.
Type B
Section Cited
CCR
80026(e)
Safeguards for Cash Resources, Personal Property and Valuables
(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

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 C2-C4's P & I money is not kept separate from other clients in care and some P & I ledgers did not have balance amounts listed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Licensee shall 1. Submit a copy of all client's P & I ledgers. Licensee may use their own form, but a balance section must be added, or LIC 405 may be used. 2. Purchase storage pouches or any other item to safe keep client's money separately from all other clients money. Submit picture evidence.
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: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/13/2024 12:44 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/13/2024 at 11:54 AM
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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

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 Administrator file was not available for review at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Administrator shall submit a written statement of the correction, print and keep all required records at the facility for review.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

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 client (C1 & C3) do not have Physician's Reports on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Licensee/Administrator shall ensure prior to accepting clients into care a Physician's Report is obtained and filed in client's file. Submit copies of LIC 602 for clients (C1 & C3).
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: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2024 12:44 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/13/2024 at 12:11 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064.3(d)
Administrator Recertification Requirements
d) 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 record review, Licensee/Administrator's certificate expired 11/29/2023, but renewal documentation was sent until 5/28/2024, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Administrator shall ensure that recertification documents are sent to the Department 90 days before expiration date.
Submit a written plan of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 09/13/2024
NARRATIVE
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Resident Rights/Information: Resident Personal Rights poster is posted. Internet access is available for residents. Physician's orders are on file. One (1) resident requires a modified diet. HCBS Rights were not observed posted.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I records. Client (C1 & C3) do not have medical assessments on file.

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.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications 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 reviewed.

Incident Medical and Dental: All residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: LIC 610D form "Emergency Disaster Plan/Disaster and Mass Casualty Plan is current.

The last Fire/Emergency Drill was conducted on 3/28/2024.

Emergency Intervention: Facility does not use de-escalation and crisis reduction techniques.

Per Title 22 deficiencies were cited.



Exit interview was conducted with 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: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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