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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801637
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:21:48 AM


Document Has Been Signed on 05/02/2024 11:21 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VETERANS HOME OF CALIFORNIA-VENTURAFACILITY NUMBER:
565801637
ADMINISTRATOR:CYNTHIA GAMBILLFACILITY TYPE:
740
ADDRESS:10900 TELEPHONE ROADTELEPHONE:
(805) 659-7501
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:60CENSUS: 57DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Cynthia Gambill TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 9:55 a.m., LPA met with Hospital Administrative Resident (HAR) II Cynthia Gambill and explained the reason for the visit.

The reason for today's inspection is to follow up on a self-reported incident dated 04/22/2024. The report pertains to Resident #1 (R1) reporting physical abuse by Staff #1 (S1). At 9:58 a.m., the LPA conducted an interview with HAR II. At 10:10 a.m., the LPA requested and obtained copies of pertinent documents. At 10:45 a.m., the LPA and HAR II conducted a brief physical plant tour.

No immediate health and safety concerns were observed during today's inspection.

Additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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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