197607966-8-16-2021-11-AS-TAGD-C5XUCR-20210816152821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607966
Report Date: 08/16/2021
Date Signed: 08/16/2021 03:29:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES		FACILITY NUMBER:	197607966
ADMINISTRATOR:	JULIAN MANALO		FACILITY TYPE:	740
ADDRESS:	11500 NIMITZ AVENUE		TELEPHONE:	(424) 832-8200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90049
CAPACITY:	84	CENSUS: 66	DATE:	08/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:12 AM
MET WITH:	Denise Davenport - Chief, Domiciliary Services		TIME COMPLETED:	02:45 PM

NARRATIVE

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On Monday, August 16^th, 2021 at 11:12pm, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Agard conducted a risk assessment in the front lobby. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for eighty-four (84) bedridden residents, of which eight (8) may be on hospice. Currently, there are no hospice residents present during today’s visit.

LPA met with Chief, Domiciliary Services, Denise Davenport and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA was properly equipped with Fit tested N-95, gown, gloves and face shield.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and an additional supply of PPE is stored in the facility storage. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation prior to the most reason case was in the resident’s bedroom and front patio area. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

LPA reviewed the facility’s surveillance testing records; unvaccinated staff are being tested twice per week and vaccinated staff, only during an outbreak or if requested. LPA observed two newly admitted residents. Which were both tested before admission.

The facility has no memory care unit associated with the RCFE. Potentially dangerous items are kept

Continued on 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES	FACILITY NUMBER: 197607966
	VISIT DATE: 08/16/2021

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inaccessible to residents.

Some rooms were visibly inspected. Beds in shared bedrooms are more than 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies are sufficient, adequate lighting provided throughout the facility, storage for resident personal belongings was observed and adequate.

Furniture throughout are separated, and 6 feet apart from each other. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. Walk-in tubs were observed and clean. The water temperature measured within range. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed more than a two-day supply of perishable and seven-day supply of non-perishable food. Knives and toxins were kept secure and away from residents. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. Fire extinguishers were observed fully charged throughout the facility.

Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

No deficiencies were cited during this visit.

No advisory notes were issued, and no technical assistance was provided.

An exit interview was conducted, and a copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

LIC809 (FAS) - (06/04)

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