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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604612
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:59:13 PM

Document Has Been Signed on 07/20/2023 02:59 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:
07/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Mark Black and DSP Somora DavidsonTIME COMPLETED:
03:00 PM
NARRATIVE
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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 then met with Administrator Mark Black, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/14/2023). According to the LIC624: on 07/14/2023, Client #1 (C1) eloped from the facility (left the facility and staff line of sight). [See LIC 811 Confidential Names List for a description of C1.] Facility staff saw C1 leave, and immediately notified law enforcement, who located C1 about a half hour later and returned them to the facility unharmed/uninjured.

During today’s visit, LPA performed a brief facility tour and welfare check, finding no safety concerns. At the time of LPA’s visit, C1 was off-site at school. LPA also reviewed pertinent care records and interviewed relevant staff.

According to C1’s latest LIC602 Physician’s Report (dated 04/14/2023), their doctor determined that C1 was unable to safely leave the facility unassisted.

Interviews and records showed that Licensee had a written Absentee Notification Plan as part of C1’s record of care, and that staff followed this plan during the incident. Licensee provided needed observation to C1 and met reporting requirements.

No deficiencies were observed or cited during today's visit.


An exit interview was conducted with Black, to whom a copy of this report, 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: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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