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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601005
Report Date: 04/03/2024
Date Signed: 04/03/2024 10:46:02 AM


Document Has Been Signed on 04/03/2024 10:46 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:VETERANS HOME CHULA VISTAFACILITY NUMBER:
374601005
ADMINISTRATOR:KATHRYN GABRIELFACILITY TYPE:
740
ADDRESS:700 EAST NAPLES COURTTELEPHONE:
(619) 205-1150
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:55CENSUS: 17DATE:
04/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Kathryn GabrielTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Case Management Visit. LPA met with Administrator Kathryn Gabriel, and we discussed the purpose of the visit.

Today's visit is in response to the self-reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away at the hospital, date of death: 3/25/2024

LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility. Additional facility records were obtained on this date regarding R1's death.

No deficiencies were cited or observed on this date.

An exit interview was conducted. Administrator Kathryn Gabriel was provided a copy of their appeal rights (LIC9056 03/22), along with a copy of this report.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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