374601005-8-9-2024-08-AS-DNGN-D7Z2NQ-20240809173308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601005
Report Date: 08/09/2024
Date Signed: 08/09/2024 05:34:14 PM

Document Has Been Signed on 08/09/2024 05:34 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	VETERANS HOME CHULA VISTA		FACILITY NUMBER:	374601005
ADMINISTRATOR:	KATHRYN GABRIEL		FACILITY TYPE:	740
ADDRESS:	700 EAST NAPLES COURT		TELEPHONE:	(619) 205-1150
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY:	55	CENSUS: 22	DATE:	08/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator Kathryn Gabriel		TIME COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Kathryn Gabriel. According to the facility’s license, the facility has a maximum capacity of fifty-five (55) residents, of which all may be ambulatory or non-ambulatory but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of five twenty (22) residents in care, of whom twenty (20) were ambulatory and two (2) were non-ambulatory and none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and none of these were present. LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple residents and multiple staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected all common areas and multiple resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 VISTA	FACILITY NUMBER: 374601005
	VISIT DATE: 08/09/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

Where tested, hot water temperature at taps accessible to residents were all compliant: Public Restroom #1 Sink was 116.6 F, Public Restroom #2 Sink was 116.1 F, Kitchenette Room Sink was 115.3 F, Laundry Room Sink was 116.2 F, Room C205 Sink was 116.2 F, Room C306 Sink was 115.3 F, Room C404 Sink was 117.3 F, and Room C408 Sink was 114.4 F. Appliances to preserve perishable food were also all compliant in temperature: Main Walk-In Refrigerators were 32 F and 37 F, respectively. Main Walk-In Freezer was -3 F. Kitchenette Refrigerator was 35 F, and Kitchenette Freezers were -3 F and 0 F, respectively. The Medication Room Refrigerator was 40 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE) and staff had been trained on PPE within the last twelve (12) months.

No deficiencies were observed or cited during today's annual inspection.

LPA issued Technical Assistance (TA) regarding medical assessments/physician’s reports and physical organization of personnel records (refer to the attached LIC 9102-TA pages).

An exit interview was conducted with Gabriel, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

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