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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801637
Report Date: 02/17/2021
Date Signed: 02/17/2021 05:11:32 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: DATE:
02/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Kevin Kielas,TIME COMPLETED:
12:13 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent Case Management Tele-Investigation regarding a self reported incident. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation began telephonically with Kevin Kielas, Hospital Administrator Resident II at 9:10 AM.

Today's Tele-Investigation is a continuation of the investigation the LPA initiated during the 09/18/2020 Case Management Tele-Inspection/Investigation. Between approximately 9:29 AM and 12:13 PM, the LPA conducted telephone interviews with Resident # 3 (R3), Resident #4 (R4), Resident # 5 (R5), and Resident #6 (R6).

Further investigation is needed. A hard copy of the report was provided via email to Mr. Kielas for signature.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
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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