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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700894
Report Date: 12/18/2024
Date Signed: 12/18/2024 01:36:20 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2024 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20240709103628
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:
12/18/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:TERESA, ODILLON STATIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Untimely medical care
Questionable Death
Reporting Requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deiver findings for the above allegations. LPA was greeted by administrator and explained the reason for the visit.

An Indepedent investagation was done by the department and based on the records reviewed, There is not enough evidence to suggest that there was a facility failure that caused R1’s SBI and death. There is no preponderance of evidence to prove the alleged violation contributed to the resident’s death or injury due to R1’s complex co-morbidities and other contributing factors. The facility was able to provide proof of reoprting the incident within the allowed time frame. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. No deficiencies were cited regarding the above allegations

Exit interview conducted. Copy of report given
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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