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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607966
Report Date: 08/14/2023
Date Signed: 08/14/2023 04:38:47 PM


Document Has Been Signed on 08/14/2023 04:38 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:VETERANS HOME OF CALIFORNIA - WEST LOS ANGELESFACILITY NUMBER:
197607966
ADMINISTRATOR:JULIAN MANALOFACILITY TYPE:
740
ADDRESS:11500 NIMITZ AVENUETELEPHONE:
(424) 832-8200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY:84CENSUS: 61DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Denise Davenport, Chief of Domiciliary TIME COMPLETED:
05:00 PM
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On Monday, August 14, 2023, at 8:49:53 am, Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arrival at the facility, LPA España conducted a risk assessment in the front lobby. LPA verified that the facility has an approved mitigation plan report. LPA conducted a telephone call to Ms. Teresa Starks, Acting Administrator for the Veteran’s Home of California, West Los Angeles effectively as of July 31, 2023. LPA met with Denise Davenport, Chief of Domiciliary and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked.

The facility is licensed for eighty-four (84) bedridden residents, of which eight (8) may be in hospice care. Currently, there are no hospice residents present during today’s visit. During the tour, LPA observed the facility’s infection control practices. 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 is in the den, telephone room, resident’s bedroom or front patio area. LPA observed required postings throughout the facility. The facility has no memory care unit associated with the RCFE. Potentially dangerous items such as toxins are kept inaccessible to residents. Some rooms were visibly inspected. Beds and bedding supplies are sufficient, adequate lighting provided throughout the facility, storage for resident personal belongings was observed and adequate. 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 of 105f-120f. 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.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES
FACILITY NUMBER: 197607966
VISIT DATE: 08/14/2023
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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.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
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