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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700894
Report Date: 12/09/2024
Date Signed: 12/09/2024 09:58:12 AM

Document Has Been Signed on 12/09/2024 09:58 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VICTORY CARE HOMEFACILITY NUMBER:
392700894
ADMINISTRATOR/
DIRECTOR:		TERESA, ODILLON STAFACILITY TYPE:
735
ADDRESS:8040 COLONIAL DRIVETELEPHONE:
(209) 679-3325
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 3DATE:
12/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Jennifer CamposTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident reports received dated 11/24/2024 and 11/30/24 for incident. LPA explained purpose of visit to staff.

The incident reports were regarding R1 and his visits to the the hospital for pain and suicidal thoughts. LPA reviewed incidents reports and interviewed R1. LPA reviewed facilities training on reporting requirements.

Per California Code of Regulations, Title 22 no deficiencies were observed during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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