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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801200
Report Date: 09/21/2021
Date Signed: 09/21/2021 03:12:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VICTORIA BOARD AND CAREFACILITY NUMBER:
486801200
ADMINISTRATOR:MENDOZA,JEANIVICFACILITY TYPE:
740
ADDRESS:219 REGENTS PARK DRIVETELEPHONE:
(707) 643-8459
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator/Licensee Jeanivic KeeneTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted 1 year required inspection and met with Administrator/Licensee Jeanivic Keene (formerly Mendoza). The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened and observed for any changes daily and all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Each exit was equipped with a working door alarm. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed all safely stored and locked away. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). Administrator/Licensee had a mask on during the LPA's inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Mitigation plan was approved by the Department on 07/28/2021. Fire clearance is approved for six (6).
There were six (6) residents in care at the facility during this inspection.
No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator/Licensee Jeanivic (Mendoza) Keene.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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