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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801637
Report Date: 02/10/2022
Date Signed: 02/10/2022 03:24:07 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: 57DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Julian BondTIME COMPLETED:
03:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with Administrator Julian Bond.

LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed hot water temperature at 113.5, 114, 114.3 and 115.6 degrees F. in resident rooms. LPA observed signal system which operates from each resident room. There is an adequate amount of perishable and non-perishable food. Outdoor area toured. PPE supplies were observed. LPA observed the fire extinguishers fully charged. The carbon monoxide detectors were tested and operable. Administrator stated that the Fire Marshall conducted a test on the smoke alarms on 7/15/21 and they passed inspection. Administrator provided LPA a copy of the Priority Inspection Report from the Department of Forestry and Fire Protection dated 7/15/21 which indicates that the facility passed inspection.

During facility tour at 1:28 pm with the Administrator LPA observed Shuffleboard Cleaner and Shuffleboard Silicone in a cabinet in the lounge accessible to residents. During facility tour at 1:32 pm with the Administrator LPA observed Sani-Cloth germicidal disposable wipes on a cart outside of the lounge accessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above as disinfectants and cleaning solutions were accessible to residents which poses an immediate health risk to persons in care.
POC Due Date: 02/10/2022
Plan of Correction
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Staff placed items in an inaccessible location during facility visit. Administrator stated that they will provide documentation of staff training regarding reguation 87309(a) to CCL by 2/21/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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