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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801200
Report Date: 10/02/2023
Date Signed: 10/02/2023 03:18:26 PM


Document Has Been Signed on 10/02/2023 03:18 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
10/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jeanivic Mendoza, AdministratorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required - 1 Year inspection and met with Jeanivic Mendoza, Administrator/Licensee. There are currently 6 residents in care. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 3.

LPA toured facility and grounds and observed required signs posted in common areas. LPA was screened upon entrance to this facility. Infection control practices are present: entry procedures, face coverings and 30-day PPE supply. Bathrooms are equipped with liquid soap and paper towels. Showers have non-skid mats and grab bars. All staff have First Aid/CPR and have received all their annual trainings.

Facility was found to be at a comfortable temperature of 69 F with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Water temperature measures 108.5 F degrees and falls within the required temperature of 105 to 120 degrees F. Fire extinguisher was found to be charged and serviced 4/25/2023. Carbon monoxide detector was tested and found to be operational. There were 9 smoke detectors which were tested and operational.

The shed in the backyard is used for storage only. The back yard and deck provide seating for residents to enjoy fresh air and views of garden.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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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