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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280109377
Report Date: 07/25/2022
Date Signed: 07/25/2022 01:25:54 PM

Document Has Been Signed on 07/25/2022 01:25 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VETERANS HOME OF CALIFORNIA TRUMAN HALLFACILITY NUMBER:
280109377
ADMINISTRATOR:ANGELA BRILESFACILITY TYPE:
740
ADDRESS:300 CALIFORNIA DRTELEPHONE:
(707) 948-2516
CITY:YOUNTVILLESTATE: CAZIP CODE:
94599
CAPACITY: 48CENSUS: 29DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Angela BrilesTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced at approximately 10:50 AM on 07/25/2022 to conduct a Required- 1 Year inspection. LPA met with administrator, Angela Briles. The inspection was focused on the infection control practices and procedures of this facility.

LPA was screened at a screening station at the front entrance to the facility. LPA was then directed to a testing station where LPA submitted to voluntary COVID testing. Administrator indicated that while it is requested of visitors, it is not mandatory. Visitors may deny testing. The RCFE portion of the facility is located in building F, Truman Hall. Campus also contains a skilled nursing section. The facility does not admit residents with a diagnosis of dementia. LPA toured building and grounds with administrator which were clean and in good repair. Exits and walkways were unobstructed. Medications were centrally stored and inaccessible to residents. Communal dining is open for residents.

Provider Information Notices (PINs) were available for review in an information resource binder located at the entrance to Truman Hall. COVID postings and hand sanitizer were observed throughout the facility. The facility has Personal Protective Equipment (PPE) and supplies to support a resident in isolation. Staff have been N95 fit tested. Infection control plan was submitted to Community Care Licensing.

LPA and administrator discussed updated infection control requirements. LPA provided a copy of regulation 87470. LPA provided guidance to make sure infection control plan matches current facility practice. LPA requested the following documents: LIC 500, LIC 610E, LIC 308, and LIC 9020.

No deficiencies cited during today's inspection. Exit interview conducted with administrator and a copy of this report left for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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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