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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700894
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:01:40 PM

Document Has Been Signed on 04/02/2024 02:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
04/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:TERESA, ODILLON STATIME COMPLETED:
02:00 PM
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On 4-2-24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit regarding incidents which occurred on 3/30/24. LPA met with licensee TERESA, ODILLON STA and explained the purpose of the visit. LPA reviewed incident reports dated 3-30-24 and facility file documentation for resident (R1). LPA also conducted health and safety facility tour as part of this case management. Additionally, LPA interviewed licensee.

On 3-30-24, facility reported that R1 passed way. on 3/09/24, R1 was found at the facility and was waking up when prompted vitals were checked and were okay but 911 was called as precaution. R1 was sent to the hospital on 3/9/24 and was placed on comfort care on 3/21/24 and then passed away at the hospital 3-30-2024. on 3/18/24 R1 was wake and lucid when licensee visited the hospital video shown to LPA. Facility provided R1's 602 (physician's report), IPP and preplacement appraisal. R1 was in the ICU 3/9/24-3/21/24.

LPA conducted facility tour with licensee. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Fire extinguisher was full charged and dated 9-15-23. Room temperature was 71*F. Smoke alarms and carbon detectors are functioning properly. Current census is 3. No obstructions to fire exits noted during today's tour. As a result of today's case management visit, no deficiencies are being cited under Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report was given.

This matter is still under investigation.

Licensee will obtain death certificate from family when available and email to LPA Lewis.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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