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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700894
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:47:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/09/2022 12:47 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 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:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH: Odillon Sta teresaTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by Staff member Odillon Sta Teresa. LPA explained the purpose of the visit to staff member. Administrator's Certificate # 6043434735 Expires 12/08/2023, Chelsea Faith Dela Vega Administrator's Certificate # 6054390735.

LPA and staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 3. There is entry door is leading to a hallway and a the living room on the right, futher done the hall is the kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care.

Hot water temperature was measured at 108 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 392700894
VISIT DATE: 11/09/2022
NARRATIVE
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LPA did observed the facility to have hand washing stations, LPA did not observed the facility to have COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA's observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

LPA observed, fire extinguishers inspected on 9/20/2022 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed three (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. Staff were finger print cleared but not associated during the visit. LPA performed Associations and provided TA for future.



LPA reviewed two (2) resident facility files. All necessary documents were not in place.

LPA observed P and I count to be Short for R1 by $111.00. Administrator provided the replacement amount during visit. A quality assurance measure should be implemented to ensure that funds are accurate. A follow up visit will be conducted by the LPA.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/09/2022 12:47 PM - It Cannot Be Edited


Created By: Kesha Lewis On 11/09/2022 at 10:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VICTORY CARE HOME
FACILITY NUMBER: 392700894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2022
Section Cited
CCR
80087(c)

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BUILDINGS AND GROUNDS: Buildings and Grounds: The facility shall be kept clean, sanitary and in good repair at all times.
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License will send via email to LPA Lewis an estimate for patio concrete replacement with in 14 days and provide a plan for residents in care to walk safely in the absence of repairs.
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This requirement was not met as evidenced by. LPA observed that the back entry to the patio and patio area is uneven and presents a fall hazard. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 392700894
VISIT DATE: 11/09/2022
NARRATIVE
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TA'S given for:

Mitigating COVID - 19 incl. entry point screening area, informational signage, and social distancing signs which were not present, but implemented during visit.

Staff and resident files to be completed and in separate binders. Walk through of ARF Self Assessment was conducted, VMRC was notified of some missing documents, a follow up visit will be conducted by LPA.

P and I count to be monitored effectively.

TSP services explained, Admin will review and notify LPA if a referral is requested.

During visit email sent providing.

Comp II I


DSS website has information and how to videos re: Guardian.
Active Certificates | Administrator Certification | Community Care Licensing
Forms and Publications (I-L)
Resource Guide for Providers (ca.gov)
Caregiver Background Check


Kesha.lewis@dss.ca.gov
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4