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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700894
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:18:08 AM

Document Has Been Signed on 10/21/2022 11:18 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VICTORY CARE HOMEFACILITY NUMBER:
392700894
ADMINISTRATOR:TERESA, ODILLON STAFACILITY TYPE:
735
ADDRESS:8040 COLONIAL DRIVETELEPHONE:
(209) 679-3325
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 2DATE:
10/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Odillon Sta TeresaTIME COMPLETED:
11:15 AM
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On 10-21-22 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a health and safety check. LPA met with Administrator Odillon Sta Teresa and explained the purpose of the visit. LPA conducted facility tour with Administrator and observed the following areas: Resident bedrooms, common areas, kitchen, garage, dining area, and outside of facility to ensure compliance with Title 22 regulations. LPA observed adequate food supply available for residents. Facility room temperature was 74*F. No obstructions to fire exits observed. Administrator and 1 staff member were present. Residents were in day program and not on site.

Facility accepted resident1 (R1) and R2 from another licensed facility on 10-20-22. Living areas for residents were clean and sanitary with no foul odors. Medications were locked, secured, and available on hand. All residents personal belongings including clothing was on site and stored appropriately. Resident's facility file documentation was on site. There were no residenst living in the facility prior to R1 and R2's admission.

No deficiencies observed during today's visit. An exit interview was conducted with Odillon Sta Teresa and a copy of this report was left with Odillon.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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