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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603562
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:20:15 PM

Document Has Been Signed on 06/23/2022 02:20 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:VICTORY RESIDENTIALFACILITY NUMBER:
198603562
ADMINISTRATOR:JOHNSON, ANTHONYFACILITY TYPE:
735
ADDRESS:730 E ALWOOD STREETTELEPHONE:
(323) 804-5062
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
06/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Anthony JohnsonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an announced Pre-Licensing visit. LPA met with Licensee Anthony Johnson and explained the reason for the visit. An application was submitted to Community Care Licensing Department (CCLD) for a change in ownership of an Adult Residential Facility to serve 4 ambulatory clients in the age range of 18 through 59. The fire clearance has been approved for 4 ambulatory clients. At the time of visit all 4 clients were in the Day Program.
LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards.
The single-story facility included: living room, kitchen, dining area, office/staff room, 3 client bedrooms
(2 private, 1 share), laundry area in the hallway, front yard and back yard. Backyard has a shaded seating area for clients use. There is a detached garage in the backyard and inaccessible to clients. The home doesn't have any pools. Windows and window screens are in good repair. There are 2 fireplaces located in the living room and in the office area which are covered by a screen. Passageways, walkways, driveway are free of obstructions. Front, back and side areas are free of hazards.
Bedrooms were observed to have the required furniture such as bed frames, dressers, chairs and sufficient closet space. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket. Extra linens, blankets, towels, and personal hygiene supplies were observed. Bathrooms are clean and have a working toilet, wash basin, bath tub/shower. LPA tested the hot water temperature and was 110.3 degrees F*, which is within the required 105 - 120 degrees. All appliances in the kitchen were observed to be clean and operational. LPA observed at least 2 days of perishable and a minimum of 7 days of nonperishable food. Knives, cutlery and the sharp kitchen utensils are stored in a locked cabinet in the laundry area. All chemicals are locked in the garage and inaccessible to clients. The home has all the required posters posted. Continue 809C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VICTORY RESIDENTIAL
FACILITY NUMBER: 198603562
VISIT DATE: 06/23/2022
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Fire extinguisher observed in the kitchen fully charged. Telephone system is land line located in the living room. LPA observed a pull-switch fire alarm system (near the main entrance). Carbon monoxide detectors in the hallway and in the client rooms are operational. The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the dining room. Resident and staff files were reviewed since the facility is currently operating. Files reviewed were complete. Applicant will be handling cash resources of clients. Cash resources are locked and stored in the office with P & I Ledger, accessible to designated staff. LPA used the inspection tool and the pre-licensing checklist for ARF during this visit.

No outstanding or pending items were observed by LPA requiring additional pre-licensing visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.


Exit interview conducted and a copy of this report was provided to Anthony Johnson.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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