Victoria Ann Elderly Care

Type of visit: Required - 1 Year

On 10/12/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Licensee, Omar Canchola. At the time of visit there was One #1 staff, one #1 volunteer and five #5 residents present. LPA toured the facility inside and out with Omar Canchola. Tour included: Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash can has tight-fitting lid. Dishwasher is used to clean and sanitize dishes. Fridge, Freezer and all need appliances were present and shown to be in working condition and clean. Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 76 degrees Fahrenheit. Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items. Medication; LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet located in the office and are distributed according to physician orders. The first aid kit was complete. Bathroom; LPA toured hall bathroom and observed bathroom to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 116 degrees Fahrenheit Continue on LIC809-C Continued from LIC809. Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Garage and Laundry; LPA tour the garage and observed garage to be clean. Washing machine and dryer are located in the garage and are in good repair and sufficient for approved capacity. Cleaning supplies are stored away in the storage room, inaccessible to clients. Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed. Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings were posted near the entryway and throughout the facility. The administrator certificate expires on 11/9/2023. Interview; Two #2 staff and three #3 residents were interviewed. No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Omar Canchola.the state’s words, verbatim · CDSS document, Oct 12, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 2:00PM, LPA met with Applicants Irina Larina and Omar Canchola. An initial application to operate a Residential Care For the Elderly (RCFE) facility was received by the Central Applications Unit (CAU) on 09/24/2021 for a total capacity of six (6) residents, five (5) of which may be non-ambulatory and one (1) may be bedridden. Fire Clearance was granted on 06/24/2022 for a total of six (6) residents, of which five (5) may be non-ambulatory and one (1) may be bedridden. During today's visit, LPA Danielson observed the following: Structure: Facility was a single story house with four (4) resident bedrooms, one (1) resident bathroom, living room, family room, dining area and kitchen. There was an attached two (2) car garage in the front of the house. The facility also has a bedroom and bathroom designated for live in staff. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector. Bathrooms: The lone resident bathroom has a working toilet, wash basin and an adequate supply of paper towels, toilet paper, and soap. LPA verified bathroom water temperature was measured at 105 degrees Fahrenheit. (CONTINUED ON LIC 812C) (CONTINUED FROM LIC809) Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in a locked room. Knives/sharp instruments were secured in a locked cabinet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents. Living/Family room: There was a living room with safe and adequate seating for all residents as well as working TV. Linens and Hygiene Supplies: An adequate supply of additional linens and hygiene supplies were stored in a locked storage room. Yards/Outside: There was a patio with adequate shaded seating for all residents. All walkways were observed to be free of obstructions. Garage: Garage was free of obstructions. Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, emergency phone numbers, emergency exit plan, resident Personal Rights, and facility visitation policy were posted as required. General items: Two (2) fire extinguishers were charged and located in the dining room and office. Smoke alarms and carbon monoxide detectors were in working order. Resident records will be stored in a locked office. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Component III was completed during today's visit and a hard copy was also provided for future reference. Pre-licensing is complete and this facility has no deficiencies. Licensure will be granted based on final approved from CAU. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 9, 2022

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Larina, Irina (Administrator and Corporate Board Member) Interview Method: Telephone interview On 1/13/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 13, 2022