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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280109377
Report Date: 03/23/2022
Date Signed: 03/23/2022 11:10:32 AM

Document Has Been Signed on 03/23/2022 11:10 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 33DATE:
03/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Angela Briles (Administrator)TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Cuadra met with Angela Briles, Administrator for a case management visit to follow-up on incident reports received on 2/7/22 involving resident (R1) and resident (R2). On 2/6/22 there was an altercation between R1 and R2. Per Administrator, the two residents are not related and this was an isolated incident. R1 has some communication limitations and was in between moving rooms and the interim period was using the day room to watch television then there was an un-witnessed altercation between R1 and R2 when staff came in the room it appears like R1 had been pushed. Staff inquired about the incident and R2 admitted that they pushed R1 because R1 was apparently switching tv channel/volume. On 2/7/22 the day after the incident social workers met with R1 to try to resolve any issues. They suggested getting their comcast service transferred to their new room and their essentials moved in immediately and facility implemented the changes. Also, Public Safety (CHP) and (ERT) Emergency Response Team responded to the RCFE to interview both residents and check on their safety and well-being.

LPA requested and obtained CHP incident Log# 1653 regarding incident and no further action is needed. During today's visit LPA reviewed records and made observations. Per Administrator, this was an isolated incident there are no changes to their needs and services plans, but the facility is still monitoring both residents very closely to prevent future incidents. Facility made the proper notifications and SOC341 was completed and forwarded to the correct parties per regulation.

LPA also followed up on a SOC341 submitted to CCL on 2/28/22. This incident is involving two residents from another section of the Veterans Home and the responsible parties including law enforcement, Ombudsman and CDPH were notified.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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