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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602605
Report Date: 01/21/2022
Date Signed: 01/24/2022 08:08:03 PM

Document Has Been Signed on 01/24/2022 08:08 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:VICTORIOUS HOME IFACILITY NUMBER:
198602605
ADMINISTRATOR:VICTORIO, JORDAN AFACILITY TYPE:
735
ADDRESS:521 FAXINA AVENUETELEPHONE:
(626) 404-8173
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 4DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Alma EnriquezTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with caregiver Anabal Paspor and explained the reason for the visit. Shortly after, the administrator Alma Enriquez arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply, Facility has submitted a mitigation plan and was approved on 04/25/21.

The facility is a one story house and located in a residential area. The facility included : living room/staff office, kitchen, dining area, three clients' bedrooms, two bathrooms and an attached garage. All three clients' bedrooms were toured. The 1st client bedroom has two beds, two dressers, sufficient closet space, required furniture and linen, and sufficient lighting. The 2nd and 3rd client bedroom has one bed, one chair, closet, dresser, required furniture and linen and sufficient lighting. All toilets, hand washing and shower are safe, sanitary and in good operation condition. The hot water was tested in two bathrooms are between 105 to 115 degrees F. The refrigerator and kitchen cabinet in the kitchen has sufficient two days perishable and seven days non perishable food. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The front and back yard are well maintained and the back yard has a shaded area and sitting area. All the sharp knife and utensils are locked in the kitchen cabinet and all the toxic and cleaning supplies are locked under the sink and garage. The clients' medication are centrally stored and locked in the medication cabinet next to the refrigerator. The smoke detector and carbon monoxide detectors were inspected and they are in good operating condition.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each room and facility is disinfected every few hours or as needed, The facility have sufficient soap, paper towels, and signs, The PPE supplies are stored for 30 days.

No deficiencies were found during the visit. Exit Interview conducted. A copy of the report was provided to administrator Alma Enriquez.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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