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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602576
Report Date: 04/11/2023
Date Signed: 04/11/2023 01:09:29 PM

Document Has Been Signed on 04/11/2023 01:09 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
GREATER LA AC/SC, 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:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Oluwatosin Iwajomo, StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection. Upon arriving at the facility, LPA met with Staff, Oluwatosin Iwajomo, and explained the purpose of the visit. Administrator, Akinwale Orunesajo, arrived at 11:30am to assist with the visit. The facility is licensed for (5) ambulatory adults ages 18 -59. There are currently 4 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center.

During the visit, the CARE tools was used for the inspection. A tour of the facility was conducted. Medications, food supplies, staff and client files were reviewed.

The facility is located in a residential area. The facility is a single-story house that consists of a living room, open kitchen and dining space, 3 client bedrooms, 1 staff office, 2 bathrooms, laundry area, and an attached garage. There are no pools or bodies of water on the premises. The client bedrooms contain the required furnishings. Bathrooms are clean. The hot water temperature was within the required range of 105 - 120 degrees F. Extra supplies of linen and personal hygiene were observed. Sufficient supplies of perishable and nonperishable foods were maintained. Smoke detectors and carbon monoxide detectors are operable. Required posters are posted by the entryway. Staff are continuing to follow the Infection Control guidance when assisting clients. Medications are centrally stored in a locked storage cabinet. LPA reviewed all 4 client medications and they are being administered as prescribed. LPA reviewed 4 client files and staff files. Client files have the required documents in their binders. Staff files also contain the required documents and training verification. The facility staff have CPI training but do not use manual restraints on clients. They have current CPR/First Aid certificates.

There were no deficiencies observed. An exit interview was conducted and this report was provided to the Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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