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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601005
Report Date: 06/23/2021
Date Signed: 06/24/2021 08:26:34 AM

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: 23DATE:
06/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Administrator, Carol BranshawTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton, conducted an unannounced case management visit at the facility. LPA gained access to the facility, identified herself to Administrator, Carol Branshaw and explained the purpose of the visit.

The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on June 14, 2021. The incident report stated that on June 10, 2021, R1 was hospitalized with an injury. On June 18, 2021, R1 passed away.

On today’s date, LPA briefly toured the facility, requested copies of facility records, and interviewed staff. Facility will provide CCL the death certificate once received. No deficiencies were cited at this time.

An exit interview was conducted with Administrator, Carol Branshaw to whom a copy of this report, LIC 811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt confirms receipt of these documents.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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