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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608844
Report Date: 01/21/2022
Date Signed: 01/21/2022 11:00:32 AM



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
01/12/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220112091939
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: 2DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Panwa GochinTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff are not following Covid-19 protocols
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit. Administrator was notified regarding the visit.
Upon entry from 9-9:15 am, LPA conducted a physical plant tour of the facility to ensure no immediate health and safety concerns. LPA did not observe any immediate health and safety issues.
It is alleged that back in November 2021 that facility staff did not wear mask due to the fact that they lived in the homes and did not feel the need to wear mask. It was also alleged that there were signs that were posted inside the facility and outside that no visitors were allowed. LPA conducted an interview with facility staff from 9:30-10am regarding these issues. Staff admitted that they didn't think they had to wear mask due to living in the facility but since being educated by Community Care Licensing and Long Term Care Ombudsman that they do wear mask while in the facility and that posters saying no visitors were taken down. During the visit today LPA observed staff to be wearing mask when answering the door and LPA did not observe any posters
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20220112091939
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: 01/21/2022
NARRATIVE
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saying no visitors. Based on the information obtained through interviews this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained and Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220112091939
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Corrected before visit. Staff admitted before to not wearing mask but after being educated have been wearing mask. LPA observed staff to be wearing mask when LPA entered the facility. LPA spoke with residents who admitted staff have been wearing mask while in the facility at all times.
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Based on interviews conducted facility staff admitted to not wearing mask in the facility due to the fact that they lived in the facility. This posed a potential health and safety issue to residents in care.
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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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3