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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280109377
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:11:51 PM


Document Has Been Signed on 09/14/2023 03:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VETERANS HOME OF CALIFORNIA TRUMAN HALLFACILITY NUMBER:
280109377
ADMINISTRATOR:THERESA JONESFACILITY TYPE:
740
ADDRESS:300 CALIFORNIA DRTELEPHONE:
(707) 948-2516
CITY:YOUNTVILLESTATE: CAZIP CODE:
94599
CAPACITY:48CENSUS: 26DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Theresa JonesTIME COMPLETED:
03:20 PM
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Licensing Program Analysts (LPAs) Bertozzi and Rummonds arrived unannounced at approximately 2:30PM to conduct a Case Management Inspection and met with Administrator, Theresa Jones.

LPAs are following up regarding a self reported incident where resident had a fall and was transported to the hospital where they were diagnosed with severe sepsis with septic shock. LPAs interviewed the nurse on site and reviewed the Physician's Report and Death Certificate.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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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