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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602605
Report Date: 05/02/2022
Date Signed: 05/02/2022 12:18:16 PM

Document Has Been Signed on 05/02/2022 12:18 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:
05/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Alma Enriquez (Administrator)TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced Case Management to the facility regarding an Incident Report received on 04/23/22 involving Client #1. Upon arrival, LPA met with Alma Enriquez (Administrator) and explained the purpose of the visit.

During today's visit, LPA interviewed Staff #1 in the living room at 12:00 pm. In regards to the incident involving Client #1, Staff #1 indicated that Client #1 rolled off the bed on 04/23/22 and sustained a small linear cut to the right upper brow area and a superficial linear cut to the right lower orbital area with minimal bleeding and minor swelling. First aid was applied and Staff #1 took Client #1 to urgent care the same day. LPA obtained a copy of the urgent records.

There were no deficiencies during today's visit.

Exit interview conducted with Alma Enriquez (Administrator) and a copy of this report provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
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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