565801637-1-9-2024-29-AS-KDUK-CZBV6Z-20240109151021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801637
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:10:25 PM

Document Has Been Signed on 01/09/2024 03:10 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-VENTURA		FACILITY NUMBER:	565801637
ADMINISTRATOR:	CYNTHIA GAMBILL		FACILITY TYPE:	740
ADDRESS:	10900 TELEPHONE ROAD		TELEPHONE:	(805) 659-7501
CITY:	VENTURA	STATE: CA	ZIP CODE:	93004
CAPACITY:	60	CENSUS: 55	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cynthia (Cindy) Gambill		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 09:15AM for an unannounced annual inspection. Upon arrival, the LPA met with Administrator/Hospital Administrative Resident II (HAR II) Cindy Gambill. Entrance interview conducted.

Beginning at 09:54AM, LPA along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Annual fire inspection was completed on 08/22/2023. No deficiencies were noted at that time. Fire extinguishers throughout the building were observed to be fully charged and inspected monthly.

RESIDENT ROOMS/RESTROOMS: The facility consists of 36 resident rooms, including both single and double occupancy. Each room contains a restroom. 10 resident rooms and their accompanying restrooms were observed during today's facility tour. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. All resident restrooms observed contained grab bars and non-skid surfaces. Water temperature was measured in various resident restrooms, and measured between 114.7 degrees Fahrenheit to 115.4 degrees Fahrenheit, which is within the required range.

KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPA observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water.

COMMON AREAS: This includes 2 (two) libraries, a gym, 2 (two) lounges, dining room, spa, laundry rooms, and common restrooms. LPA observed a fireplace, which was adequately screened, in the dining area. LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Other required postings were observed in the common hallways. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VETERANS HOME OF CALIFORNIA-VENTURA	FACILITY NUMBER: 565801637
	VISIT DATE: 01/09/2024

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OUTDOOR SPACE: LPA and Administrator toured the outside area of the facility. There are various outdoor gardens, a common courtyard, parking areas, as well as multiple shaded seating areas for resident use. All passageways were observed to be clear and free of hazards.

RECORD REVIEW: LPA reviewed records beginning at 10:35AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) resident files observed were in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's Infection Control Plan and the Emergency Disaster Plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency Disaster Plan was observed to be complete and updated annually as required. Fire drills are conducted monthly, with the last fire drill documented on 12/12/2023. Last earthquake drill was conducted on 10/19/2023.

MEDICATION REVIEW: Beginning at 01:35PM, LPA reviewed Medication Administration Records (MAR) for 3 (three) residents. All items observed were in compliance with regulation.

INTERVIEWS: During today's visit, LPA interviewed four (4) staff and four (4) residents.

During today's visit, LPA obtained a copy of the facility's liability insurance as well as an updated Personnel Roster.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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