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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602576
Report Date: 04/30/2024
Date Signed: 04/30/2024 11:34:03 AM

Document Has Been Signed on 04/30/2024 11:34 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
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:
04/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Samson Iwajomo, Staff TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to complete the annual inspection. LPA met with Staff Samson Iwajomo and explained the reason for the visit. The initial visit was held on 4/25/24.

During the visit today, LPA continued the remainder of the CARE tool domains. The following were observed:
Staffing: Per administrator, there is sufficient staffing and an awake staff for the overnight shift to provide supervision.
Personnel Records-Training: Administrator (Akinwale Orunesajo) certificate expires on 6/11/25 and the HIV & TB certificate was issued on 2/5/23. LPA reviewed 3 other staff files and they have the required documents on file. They are receiving on-going training and medication training every year. Staff have current CPR & First Aid certificates.
Clients Rights-Information: Clients are provided with internet access.
Client Records-Incidents: LPA reviewed 4 client files and they all have the required documents such as admission agreement, medical assessment with TB test results, client rights, personal valuable and cash resource forms. Clients have current IPP and behavioral assessments on file.
Health-Related Services: Clients medications are centrally stored and locked. All 4 clients' medications were reviewed and are being given as prescribed.
Incidental Medical Services: There are no clients with restricted or prohibited health conditions.
Disaster Preparedness: Facility has the updated LIC610D Emergency Disaster Plan with emergency procedures listed. There are at least 2 relocation sites and directions to turn off valves.
Emergency Intervention: Staff have CPI training and do not utilize any restraints on clients.

There are no deficiencies observed during the visit today. 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: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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