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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607966
Report Date: 11/23/2022
Date Signed: 11/23/2022 02:08:58 PM


Document Has Been Signed on 11/23/2022 02:08 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
CCLD Regional Office, 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: 53DATE:
11/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Keith Gaines, Resident Care SpecialistTIME COMPLETED:
02:01 PM
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On 11/23/2022 at 12:30pm Licensing Program Analyst (LPA) Agard conducted an unannounced Plan of Correction Inspection and met with Keith Gaines, Resident Care Specialist. During today’s visit LPA attempted to verify the plan of correction cited on 10/24/2022 had been corrected as agreed in the licensee’s Plan of Correction.

During today’s visit, Administrator Julian Manalo, requested additional time to complete the plan of correction. Stating the corrections will be completed by December 9th, 2022. LPA Agard agreed to the extension and will follow up with Licensee as due date approaches.

An exit interview was conducted, and a copy of this report was given.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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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