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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601133
Report Date: 12/18/2023
Date Signed: 12/18/2023 04:36:20 PM

Document Has Been Signed on 12/18/2023 04:36 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:VICTORIA'S HOUSEFACILITY NUMBER:
385601133
ADMINISTRATOR:WILLIAMS,DARNELLFACILITY TYPE:
735
ADDRESS:658-666 SHOTWELL STTELEPHONE:
(747) 215-2500
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 46CENSUS: 39DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Darnell Williams, Executive Director TIME COMPLETED:
04:45 PM
NARRATIVE
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On December 18, 2023 at 12:30 PM, Licensing Program Analyst(LPA) John Calandra and Licensing Program Manager(LPM) Jackie Jin arrived at the facility to conduct an unannounced Annual 1-year required inspection. LPA Calandra and LPM Jin met with Darnell Williams, Administrator.

LPA Calandra and LPM Jin toured the physical plant which consists of 23 bedrooms and 9 bathrooms, kitchen, dining room, common spaces and offices. The facility is kept at a comfortable temperature of 72 degrees Fahrenheit. No accessible bodies of water were observed and all hallways, front and backyard were observed to be free of hazards. All fire extinguishers were observed to be fully charged and last checked on 12/1/2023. Two days of perishables and 7 days of non-perishables were observed in the facility kitchen. No food has expired. Water temperature was measured at a comfortable 105.9 Fahrenheit.

Centrally Stored Medications and Sharp objects, were observed to be locked and in-accessible to persons in care.

LPA and LPM reviewed 3 staff files and 6 resident files.

LPA and LPM reviewed medication records for 6 residents and all were observed to be in order.

Water in a shower on the ground floor was observed to measure at 95 degrees Fahrenheit. LPA and LPM advised Administrator, Darnell Williams to increase the temperature of water and advised Administrator to check showers regularly.

Carpet in Food Storage room was observed with red stains.

Based on observation, LPA and LPM observed two faucets in resident bathrooms that were spraying outside of the sink.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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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Document Has Been Signed on 12/18/2023 04:36 PM - It Cannot Be Edited


Created By: John Calandra On 12/18/2023 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VICTORIA'S HOUSE
FACILITY NUMBER: 385601133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 doorways in which water was leaking from the roof into a bucket, carpet in food storage room was stained red, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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Licensee shall develop an action plan on how they plan to ensure the leaking doorway will be repaired and submit action plan to CCLD by 12/19/2023. Licensee shall also submit plan of action on how they plan to clean up food storage room via photo or written documentation by 12/19/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2023 04:36 PM - It Cannot Be Edited


Created By: John Calandra On 12/18/2023 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VICTORIA'S HOUSE
FACILITY NUMBER: 385601133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 instances in which faucets in resident bathrooms had water was spraying outside of the sink, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Licensee shall repair the faucets in bathrooms and submit a photo or written documentation showing that work was completed to CCLD by 12/27/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: VICTORIA'S HOUSE
FACILITY NUMBER: 385601133
VISIT DATE: 12/18/2023
NARRATIVE
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LPA and LPM also observed a doorway that was leaking water on to the floor into a bucket.

Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

Annual will be continued at a later date.

A copy of this report and appeal rights were provided. Acknowledgement of report is given to Darnell Williams, Administrator.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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