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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602576
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:03:43 PM

Document Has Been Signed on 04/25/2024 04:03 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/
DIRECTOR:
ORUNESAJO, AKINWALE VICTORFACILITY TYPE:
735
ADDRESS:202 CALLE DESCANSOTELEPHONE:
(818) 448-3012
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 5CENSUS: 4DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Vivian Anyaegbu, Staff TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 4/25/24. LPA arrived unannounced and met with staff, Vivian Anyaegbu. The purpose of the visit was explained. Administrator, Victor Orunesajo, arrived shortly after. The facility is licensed for (5) ambulatory adults ages 18 -59.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tool and the following domains were reviewed:
Physical Plant & Environment Safety: The facility is a single-story home that consists of 3 Client bedrooms, 1 Staff office, 2 bathrooms, living room, open kitchen and dining area, laundry room, and attached garage. There are no pools or bodies of water on the premises. The client bedrooms contain the required furnishings. The hot water temperature was measured within the required range of 105-120 degrees F. Facility keeps extra supplies of linen and personal hygiene. Smoke detectors and carbon monoxide detectors are operable. Required posters are posted by the entryway.
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once during each shift and more often for high touched surfaces. Facility has sufficient PPE supplies.
Operational Requirements: The facility is licensed for (5) ambulatory adults ages 18 - 59. There are currently 4 clients residing at the home and receive services through the San Gabriel/Pomona Regional Center.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Freezers are maintained at a temperature of 0 degree F and the refrigerators at a maximum of 45 degrees F. They are kept clean and foods are properly stored.

LPA will return another day to complete the remainder of the domains. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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