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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607966
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:54:48 AM


Document Has Been Signed on 09/19/2024 11:54 AM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:VETERANS HOME OF CALIFORNIA - WEST LOS ANGELESFACILITY NUMBER:
197607966
ADMINISTRATOR:TERESA STARKSFACILITY TYPE:
740
ADDRESS:11500 NIMITZ AVENUETELEPHONE:
(424) 832-8200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY:84CENSUS: 57DATE:
09/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:De Von Young/AdministratorTIME COMPLETED:
11:55 AM
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On 09/19/24, Licensing Program Analyst LPA Alfonso Iniguez conducted a Case Management visit to clear plan of correction. De Von Young/Administrator greeted LPA, and LPA explained the purpose of the visit.

On 8/17/24, LPA Iniguez conducted an unannounced, one-year-required visit at the location. During the annual inspection, LPA Iniguez was not able to observe residents' records since they were not available for inspection.

LPA Iniguez inspected the following documents:

-Residents Records: (R#1-R#5)
-Staff Records: (S#1)

LPA Iniguez was able to review missing records, the plans of correction has been cleared.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to DeVon Young / Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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