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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601005
Report Date: 08/25/2020
Date Signed: 08/25/2020 02:39:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VETERANS HOME CHULA VISTAFACILITY NUMBER:
374601005
ADMINISTRATOR:CAROL BRANSHAWFACILITY TYPE:
740
ADDRESS:700 EAST NAPLES COURTTELEPHONE:
(619) 205-1488
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:55CENSUS: 30DATE:
08/25/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrators Thui Mascorro and Carol BranshawTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Case Management tele-visit to investigate a resident’s death. This visit was conducted via FaceTime, due to COVID-19. LPA identified himself and discussed the purpose of the call with Administrators Thui Mascorro and Carol Branshaw.

The purpose of the LPA’s visit was to discuss a self-reported death report received in our office on 08/25/2020. During today’s visit, LPA virtually toured the facility, interviewed staff and requested copies of resident records. Residents were observed and no health or safety issues were identified. No deficiencies were observed during today’s visit.

An exit interview was conducted with Administrator Branshaw via FaceTime. A copy of this report along with the Licensee/Appeal Rights (LIC 9058 01/16) and Confidential Names (LIC 811) were provided via email to Administrator Branshaw. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
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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