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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605175
Report Date: 04/07/2022
Date Signed: 04/07/2022 12:59:46 PM

Document Has Been Signed on 04/07/2022 12:59 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOCHIN CARE FACILITYFACILITY NUMBER:
197605175
ADMINISTRATOR:RHODA GOCHINFACILITY TYPE:
735
ADDRESS:8112 LOMA VERDE AVENUETELEPHONE:
(818) 349-1767
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 4CENSUS: 5DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rhoda GochinTIME COMPLETED:
01:05 PM
NARRATIVE
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At 9:35 a.m. on 04/07/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA, staff, and Administrator toured the facility inside and out.

The facility was last inspected on 07/20/2021 as part of a complaint investigation. The facility is a single story building with 4 bedrooms, 2 bathrooms, kitchen, laundry room, living room, guest house, front yard, and back yard. The facility has an approved fire clearance for ambulatory residents.

Entry: Staff screened LPA for temperature upon entry. LPA recorded contact tracing information and name in visitor log. LPA advised licensee to screen for symptoms and include temperature and symptoms on visitor log. The screening station contained a digital thermometer, hand sanitizer, N95 masks, and gloves. LPA observed facility sketch and emergency contacts posted at the front. COVID precautions were posted throughout the facility. Confidential complaint poster and facility license posted in the dining area.

Bedrooms: The facility has 4 bedrooms. Bedroom #1 is designated for staff. No hazards were observed inside. Bedroom #2, Bedroom #3, and Bedroom #4 are all shared bedrooms designated for clients. All bedrooms contained a nightstand, dresser or storage, lamp, and beds with adequate bedding. All beds were at least 6 feet apart for physical distancing. Windows, furniture, and floors were clean and in good repair. At 9:53 a.m. LPA observed 5 shaving razors beside a bed in Bedroom #2 which were accessible to clients. Staff confirmed the client purchased the razors recently, though the facility typically locks all hazardous items. Staff locked the razors away immediately.

Bathrooms: The facility contains 2 bathrooms. The bathroom designated for clients contained liquid soap, a handwashing instruction sign, a trash can with a tight fitting lid, a non skid mat in the shower, and grab bars by the toilet and shower. Staff stated paper towels are provided upon request, and clients have access to personal hand towels. At 9:50 a.m. LPA measured the sink water to be 131.8 degrees Fahrenheit.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOCHIN CARE FACILITY
FACILITY NUMBER: 197605175
VISIT DATE: 04/07/2022
NARRATIVE
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Common areas: All common areas were clean and in good condition. LPA observed two locked storage closets in the hallway. Locked closets contained sharp objects and hygiene supplies. An unlocked storage cabinet between the locked cabinets contained an adequate supply of clean linens.

Kitchen: LPA observed an adequate supply of perishable and non-perishable food in the kitchen. The house telephone is located on the counter. Sharp objects were locked above the oven. Cleaning solutions were locked under the sink. Medications were locked in a cabinet by the table. All surfaces were clean and free from debris.

Laundry Room: LPA observed a client using laundry machines. Both were operable. Detergent was locked above the dryer.

Outdoor area: LPA observed two covered grills and a covered patio area. Furniture was in good condition. The back gate leading to an alley was unlocked.

Garage: The garage was locked. LPA observed tools and additional food supplies inside.

Guest House: The guest house was locked, clean, and free from hazards. Staff stated it serves as a visitation area.

Safety: The facility has 3 emergency exits. Emergency exit paths were unlocked and free from hazards. At 9:51 a.m. the Carbon Monoxide detector in the hallway was tested and operational. At 9:55 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/19/2021. At 9:57 a.m. smoke alarms in Bedroom #2 and Bedroom #4 were tested and operational.

During today's visit, the facility is not in compliance with Title 22 regulations. Citations issued on LIC 809-D.

Exit interview conducted. Copy of report, appeal rights, and citations issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2022 12:59 PM - It Cannot Be Edited


Created By: Nicholas Reed On 04/07/2022 at 12:18 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: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 observation and interview, the licensee did not comply with the section cited above in 5 out of 5 razors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Razors locked immediately during inspection. Licensee will issue training to all staff and submit proof to LPA by POC due date.
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:Cassandra Harris
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2022 12:59 PM - It Cannot Be Edited


Created By: Nicholas Reed On 04/07/2022 at 12:29 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: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 faucet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Water heater was turned down to low during inspection. Licensee to acquire a thermometer and provide proof of temperature correction to LPA by POC due date. Licensee to create a 5-day water temperature log.
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:Cassandra Harris
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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