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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604612
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:29:14 PM

Document Has Been Signed on 06/19/2023 03:29 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VICTORIOUS LIVING RESIDENCEFACILITY NUMBER:
374604612
ADMINISTRATOR:GONZALEZ, EDUARDO JR.FACILITY TYPE:
735
ADDRESS:9231 GOLONDRINA DRTELEPHONE:
(619) 303-0560
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 4CENSUS: 3DATE:
06/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:DSP Somora DavidsonTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Somora Davidson. LPA also spoke via phone with Administrator Eduardo Gonzalez Jr.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/13/2023). According to the LIC624: on 06/12/2023, Client #1 (C1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] C1 returned to the facility unharmed/uninjured a few hours later.

During today’s visit, LPA performed a facility tour and welfare check, interviewing C1 and verifying they were indeed unharmed/uninjured, as were their peers. LPA also reviewed pertinent care records and interviewed relevant staff.

C1’s Face Sheet showed they were diagnosed with “Mild Intellectual Disability." However, according to C1’s latest LIC602 Physician’s Report (dated 04/19/2023), their doctor determined that C1 was able to safely leave the facility unassisted. The doctor also wrote that C1 was not confused, and was able to communicate needs and follow instructions.

Interviews and records showed: Licensee had an Absentee Notification Plan as part of C1’s record of care, and that staff followed it during the incident. There did not exist a preponderance of evidence showing staff did not provide needed observation to C1. No deficiency was cited for the incident.


[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VICTORIOUS LIVING RESIDENCE
FACILITY NUMBER: 374604612
VISIT DATE: 06/19/2023
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[CONTINUED FROM LIC 809]

Also, no deficiency was cited during today’s licensing visit, but LPA provided Technical Assistance (TA) and education regarding one of the facility's smoke detectors.

An exit interview was conducted with Davidson, to whom a copy of this report, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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