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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 04:37:52 PM


Document Has Been Signed on 08/14/2023 04:37 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Denise Davenport, Chief of Domiciliary TIME COMPLETED:
05:00 PM
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LPA David España conducted an unannounced case management visit to the above facility. During visit, LPA met with staff person(s) Teresa Starks, Denise Davenport and Julius Lozano and made a completed tour of facility which included: 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.

LPA addressed Decision and Order Notice Regarding Petition for Reinstatement (Gov Code section 11522) Notice of Time Limits for Reconsideration for Jesse Limon: CDSS No. 7923115006. LPA and Teresa Starks, Denise Davenport and Julius Lozano agreed that Jesse Limon would be disassociated to the facility by August 15, 2023. LPA noted that Teresa Starks, Denise Davenport and Julius Lozano were unaware of Jesse Limon as an employee at the facility (Jesse Limon / CDSS No. 7923115006 / Subject ID No. 7517383831).

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
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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