<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605175
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:54:04 PM

Document Has Been Signed on 08/27/2024 02:54 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOCHIN CARE FACILITYFACILITY NUMBER:
197605175
ADMINISTRATOR/
DIRECTOR:		RHODA GOCHINFACILITY TYPE:
735
ADDRESS:8112 LOMA VERDE AVENUETELEPHONE:
(818) 349-1767
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 4CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Rhoda GochinTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/27/24, 10:25AM Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual visit to this facility. LPA met with Facility Administrator, Rhoda Gochin and reason for the visit was disclosed.

Facility is licensed as a single-story residence for four (4) ambulatory residents assessed as mentally disabled. Facility has four (4) total bedrooms; one bedroom is shared, two bedrooms are private, and a fourth bedroom is designated for staff only. Total of two (2) bathrooms.

At 11:15 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access, and two emergency exits located in the rear of dining room and the laundry room. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 70.0°F. within the required range. An approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted on 7/05/2024.

Fire Detection sensors are present in the facility. A carbon monoxide detector, located in the hallway, was tested and observed as working properly. Smoke Alarms in Bedrooms #2,#3, and #4 were tested and observed to be working properly. LPA observed one (1) fire extinguisher located in the kitchen area. Extinguisher displays service date: 05/09/2024.

[LIC 809C Continued]

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOCHIN CARE FACILITY
FACILITY NUMBER: 197605175
VISIT DATE: 08/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Kitchen: At 11:35 AM, LPA observed kitchen as clean, equipped with a functional stove, multiple appliances, with adequate supply of perishables and non-perishable food. Open pantry space stores emergency dry food, condiments, and can goods. Food is observed as properly labeled and stored. Kitchen cabinets store dishes, plastic, paper goods and utensils. Knives and sharps are secured in a locked cabinets and inaccessible to residents.

Medications are stored in a secured file cabinet in dining room area and is inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete.



Laundry area is located in a room adjacent to the kitchen. Laundry soaps and other cleaning agents are stored in living room area closet and inaccessible to residents. LPA observed a hallway area storage cabinet which appeared to contain towels, clean linen and blankets sufficient for residents.

Commons: LPA observed all common areas of the facility, including the living room and resident dining area. LPA observed common areas to be clean and organized. Furniture provides adequate seating for residents and is in good condition. There is a fireplace that is screened off and non-operational. No fireplace tools or fixtures present.

Bedrooms are observed as clean with sufficient lighting, properly furnished with sufficient closet space, bedding, linens, at least one chair, and nightstand.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 118.6°F. Within the required range.

Garage is detached from the house which was observed to be locked, and inaccessible to residents. Garage is also used as storage for PPE supplies, wheelchairs, bedframes and other supplies for resident needs.

Outdoor (backyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. The back gate leading outside the facility perimeter is observed and unlocked and unobstructed. All trash cans were observed to be covered. There are no bodies of water in the facility.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOCHIN CARE FACILITY
FACILITY NUMBER: 197605175
VISIT DATE: 08/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident records: A File Cabinet in the living room area was observed by LPA as locked and inaccessible to residents. While LPA conducted review of resident files, LPA observed the following:

Resident Files:
  • Resident#1 (R1)- Consent files and Personal Rights were incomplete and unsigned. All other resident records for R1 appeared to be complete and current.
  • Resident#2 (R2)- Personal Rights were incomplete and unsigned. All other resident records for R2 appeared to be complete and current.
  • Resident#3 (R3)- Consent files and Personal Rights were incomplete and unsigned. All other resident records for R3 appeared to be complete and current.
  • Resident#4 (R4)- Consent files and Personal Rights were incomplete and unsigned. All other resident records for R4 appeared to be complete and current.

Staff records: A File Cabinet in the living room area was observed by LPA as locked and inaccessible to residents. A total of four (4) Staff files were reviewed. Criminal record clearances were present, and Staff records appear to be complete and current.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited: (Refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/27/2024 02:54 PM - It Cannot Be Edited


Created By: Raymond Comer On 08/27/2024 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOCHIN CARE FACILITY
FACILITY NUMBER: 197605175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)

87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in (4) out of (4) residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
1
2
3
4
Licensee has agreed to have all residents and responsible parties sign the incomplete paperwork and submit proof by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Eva Miller
LICENSING EVALUATOR NAME:Raymond Comer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4