197608844-10-29-2020-31-AS-CHAS-C3TTDA-20210609143800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608844
Report Date: 10/29/2020
Date Signed: 10/29/2020 07:34:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2020 and conducted by Evaluator Wendell Smith

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200825092541

FACILITY NAME:	TRIUMPHANT ELDERLY CARE LLC		FACILITY NUMBER:	197608844
ADMINISTRATOR:	RHODA K. GOCHIN		FACILITY TYPE:	740
ADDRESS:	8106 LOMA VERDE AVENUE		TELEPHONE:	(818) 718-0978
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 3	DATE:	10/29/2020
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Rhoda Gochin		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

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Adult poses as a risk to residents while in care
Resident sustained a fall while in care
Staff threatens resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted a subsequent complaint visit for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually over Facetime with Rhoda Gochin. LPA previously made a virtual visit on 8/31/2020.

Adult poses a risk to residents while in care
It is alleged that staff #1 (S1) is under the influence when working at the facility. LPA conducted interviews with the administrator, S1, and residents. Information obtained from interviews reveal that S1 has not been under the influence while at work in the facility. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200825092541

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TRIUMPHANT ELDERLY CARE LLC	FACILITY NUMBER: 197608844
	VISIT DATE: 10/29/2020

NARRATIVE

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Resident sustained a fall while in care
It is alleged that resident #1 (R1) had a fall in the facility went to the hospital and passed away. LPA conducted interviews with staff and residents. Information obtained revealed that R1 passed away in the facility on 7/27/2020 and was receiving hospice care. R1 did not have any recent falls in the facility prior to passing away. Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time.

Staff threatens resident while in care
It is alleged that R2 has been bullied and threatened after making suggestions to the administrator. LPA conducted interviews with R2, other residents, and the administrator. Information from interviews reveal that R2 has not been threatened or bullied by the administrator. Based on information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report emailed to administrator for signature. Hard copy on file.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020

LIC9099 (FAS) - (06/04)

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