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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280109377
Report Date: 11/05/2020
Date Signed: 09/15/2021 11:09:26 AM

Document Has Been Signed on 09/15/2021 11:09 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VETERANS HOME OF CALIFORNIA TRUMAN HALLFACILITY NUMBER:
280109377
ADMINISTRATOR:CHANELL VELLENOWETHFACILITY TYPE:
740
ADDRESS:300 CALIFORNIA DRTELEPHONE:
(707) 948-2516
CITY:YOUNTVILLESTATE: CAZIP CODE:
94599
CAPACITY: 48CENSUS: 29DATE:
11/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Chanell Vellonoweth/Angela BrilesTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Angela Elliott met with Channell Vellenoweth Chief of Domiciliary Service and Angela Briles, Hospital Administrative Resident II for a case management via tele-visit to follow-up on information received on 10/19/2020 and 10/23/2020 for R1. This case management is being conducted via tele-visit due to COVID-19 precautions. LPA requested additional documentation for review as well as a written statement from Chief of Domiciliary Service regarding R1's transition to a different level of care.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2020
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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