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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801637
Report Date: 10/22/2020
Date Signed: 10/22/2020 02:18:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VETERANS HOME OF CALIFORNIA-VENTURAFACILITY NUMBER:
565801637
ADMINISTRATOR:JULIAN BONDFACILITY TYPE:
740
ADDRESS:10900 TELEPHONE ROADTELEPHONE:
(805) 659-7515
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:60CENSUS: 58DATE:
10/22/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kevin Kielas, HAR IITIME COMPLETED:
01:44 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent Case Management Tele-Inspection regarding a self reported incident. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted telephonically with Kevin Kielas, Hospital Administrator Resident II.

Today's inspection is to continue the investigation the LPA initiated during the 09/18/2020 Case Management Tele-Inspection.

During today's tele-inspection, the LPA conducted telephonic interviews with Staff #2 and Staff #3 beginning at 1:07 PM.

Further investigation is needed. A telephonic exit interview was conducted with Kevin Kielas, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
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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