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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700894
Report Date: 01/06/2023
Date Signed: 01/06/2023 11:32:02 AM

Document Has Been Signed on 01/06/2023 11:32 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
SACRAMENTO AC/SC, 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: 3DATE:
01/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TERESA, ODILLON STATIME COMPLETED:
12:00 PM
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LPA Kesha Lewis made an Unannounced case management visit to this facility on 1/06/2023. LPA Lewis was met by the facility administrator and explained the purpose of the visit. LPA conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. An interview was conducted with the administrator and the facility was toured .

LPA Lewis also reviewed resident records to check for completeness, all necessary documents were in place. The patio in back yard and been removed and a new patio poured (Photos Taken).

Based on inspection, and documentation reviewed during this case management, the department has closed this case management and no further investigation is required. No deficiencies were cited as a result of today’s visit.

An exit interview was conducted and a copy of this report was left.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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