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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608844
Report Date: 11/01/2021
Date Signed: 11/01/2021 03:46:42 PM

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:TRIUMPHANT ELDERLY CARE LLCFACILITY NUMBER:
197608844
ADMINISTRATOR:RHODA K. GOCHINFACILITY TYPE:
740
ADDRESS:8106 LOMA VERDE AVENUETELEPHONE:
(818) 718-0978
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 4DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Solomon GochinTIME COMPLETED:
03:45 PM
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At 1:40 pm Licensing Program Analysts (LPA) Eleza Jackson conducted an unannounced annual inspection using the Annual Inspection Tool. A physical tour was conducted at 1:45pm and the following was observed:

Infection control: Upon arrival, Caretaker Panmwa took LPA Jackson’s temperature and was asked to sign-in the visitors’ log. Proper signage was observed inside of the facility. Administrator stated they have sufficient PPE supplies for residents and staff.

Food Inspection: LPA Jackson observed there to be sufficient supply of perishable and non perishable foods. Food storage and preparation appear to be clean and inaccessible to pests.

Smoke detectors/carbon monoxide were deemed to be in operating condition. Fire extinguisher is up to code.

Resident rooms: All residents bedrooms were properly furnished, had sufficient lighting and appeared to be clean and had appropriate bedding.

Bathrooms: LPA Jackson observed appropriate hand washing signs posted in the bathroom, grab bars and non-skid mat.

Laundry service: LPA Jackson observed that the cleaning products/chemicals are inaccessible to residents within the laundry room..



Medications are centrally stored and locked.
Outside areas: LPA Jackson toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed that the backyard pool is properly gated for safety.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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