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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603562
Report Date: 10/07/2023
Date Signed: 10/07/2023 04:17:42 PM

Document Has Been Signed on 10/07/2023 04:17 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:LUCAS, OMOBOLANLEFACILITY TYPE:
735
ADDRESS:730 E ALWOOD STREETTELEPHONE:
(323) 804-5062
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 3DATE:
10/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Asanya ChukwuebukaTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Asanya Chukwuebuka who assisted with the visit. Licensee Anthony Johnson and Back up Administrator Adejoke Johnson arrived shortly after. LPA explained the reason for the visit.

The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59. There are currently 3 clients residing at the home and receive services from San Gabriel / Pomona regional Center. Two (2) clients were out with families at the time of visit.

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. There are 2 fireplaces located in the living room and in the office area which are covered by a screens. Backyard has a shaded seating area for clients use. There is a detached garage in the backyard and inaccessible to clients. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the garage. Sign in sheet, hand sanitizer, gloves and masks are available.

Client bedrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathrooms were toured. Bathrooms are clean and have the required hygiene items. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. Extra linens, blankets, towels, and personal hygiene supplies were observed. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients.

Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2023
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: 10/07/2023
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Fire extinguisher observed in the kitchen fully charged. 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.

LPA reviewed client files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.


No deficiency was observed during today's visit. Exit interview was conducted with the Administrator and a copy of report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2023
LIC809 (FAS) - (06/04)
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