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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801637
Report Date: 03/25/2022
Date Signed: 03/25/2022 02:07:21 PM

Document Has Been Signed on 03/25/2022 02:07 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, 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: 55DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Julian BondTIME COMPLETED:
02:06 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management visit to the facility. The case management visit is being conducted to discuss alleged incidents that were reported to Community Care Licensing on 3/17/22 regarding resident #1 (R1) and staff #1 (S1).

During today's visit LPA toured the facility with the Administrator, conducted interviews with random staff and residents, reviewed R1's records, and obtained copies of pertinent documents. LPA will need to return at a later to continue the investigation.



No citations were issued during today's visit.

Exit interview conducted. Today's report was reviewed and emailed to the Administrator.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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