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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602576
Report Date: 05/09/2022
Date Signed: 05/09/2022 11:44:43 AM

Document Has Been Signed on 05/09/2022 11:44 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:VICTORIOUS RESIDENTIAL HOME IIFACILITY NUMBER:
198602576
ADMINISTRATOR:ORUNESAJO, AKINWALE VICTORFACILITY TYPE:
735
ADDRESS:202 CALLE DESCANSOTELEPHONE:
(818) 448-3012
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 5CENSUS: 4DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Oluwagbemiro Odofin, AdministratorTIME COMPLETED:
12:00 PM
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On 5/9/22 at 9:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of an annual required inspection. LPA met with Staff 1(S1) and explained the purpose of today's visit. Administrator Oluwagbemiro Odofin arrived at 10:30 a.m., and assisted LPA with today's visit.


The facility is licensed to serve 5 clients between the age of 18 and 59 years old with all 5 being ambulatory. The facility is a single-story building in a residential area, with a commercial kitchen, dining room, 3 bedroom, 1 office, 2 bathrooms. Facility also has a front yard, backyard, and a garage. Upon arrival LPA observed front yard clean and well maintained and 2 vehicles parked in the driveway. Administrator certificate # 6002604735 expires 6/11/2023.

LPA observed the kitchen to be clean. The kitchen cabinet are in the process of being renovated. Administrator stated they will start next week. LPA observed the shipment in the new cabinets in the backyard. LPA observe sufficient food supplies of 7 days of non-perishable and 2 days of perishables. Dining room was observed to be clean with sufficient lighting and no tripping hazards. Living room was clean and with a comfortable temperature. Bedrooms #1, #2, and #3 was observed to have the required furnishings, bedding, and linens. Hallways was clean and free from clutter/ tripping hazards. Staff office is observed locked with cleaning supplies, PPE supplies, reserved linens and food supplies. Facility has a fire extinguisher located in the Kitchen and smoke detector/ carbon monoxide throughout the facility fully tested in working condition. Bathroom # 1 and #2 is observed to be clean with skid matts/ strips. Water temperature measured at 114.8- 117.1 degrees F, which meet licensing requirements of 105-120 degrees F. LPA toured the garage and observed it to be clean and well maintained.

Report continued on 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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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: VICTORIOUS RESIDENTIAL HOME II
FACILITY NUMBER: 198602576
VISIT DATE: 05/09/2022
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The garage is used to store PPE supplies, emergency food supplies and other furnishing items. The facility back yard was clean with no debris or tripping hazards with ample shade for the clients. Medications for all clients was reviewed and appears to be given as prescribed. Administrator and S1 files were also reviewed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to administrator Oluwagbemiro Odofin.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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