197608844-11-15-2022-31-AS-NRED-CL7SFW-20221115125101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608844
Report Date: 11/15/2022
Date Signed: 11/15/2022 12:51:15 PM

Document Has Been Signed on 11/15/2022 12:51 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:	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: 6	DATE:	11/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Rhoda Gochin		TIME COMPLETED:	12:55 PM

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At 11:35 a.m. on 11/15/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 11/01/2021 for an annual visit. It is a single story building with 3 bedrooms, 2 bathrooms, kitchen, garage, common areas, pool, and outdoor areas. It has an approved fire clearance for 6 ambulatory residents, of which 1 may be bedridden. Approved hospice waivers for 3.

A file review was conducted prior to inspection. 2 out of 2 facility staff present maintained criminal background clearances.

Upon entry, LPA observed surveillance cameras on the facility’s exterior. Signs were posted denoting the use of cameras and oxygen tanks in the facility. A ramp in good condition with sturdy handrails led to the main entrance. Once inside, LPA observed additional postings for the facility’s COVID policies, facility license, personal rights, emergency disaster plan, confidential complaint contacts, ombudsman contacts, and emergency contacts.

LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, gloves, surgical masks, hand sanitizer, and a visitor log.

At 11:55 a.m. LPA tested the dual-purpose smoke and carbon monoxide detector in the hallway to be operational. LPA also observed a fully charged fire extinguisher at the main entrance. It was last inspected on 05/23/2022.

The facility had 3 shared bedrooms. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. All beds were at least 6 feet apart to maintain social distance. LPA observed sliding locks on the exit doors of Bedroom #1 and Bedroom #2. The Administrator unlocked the sliding locks after guidance from LPA.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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: TRIUMPHANT ELDERLY CARE LLC	FACILITY NUMBER: 197608844
	VISIT DATE: 11/15/2022

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1 out of 2 beds contained full bed rails in Bedroom #1. Administrator confirmed the resident was on hospice. A ramp in good condition extended from Bedroom #1 and Bedroom #2 to the emergency exit. Exit paths were free of obstructions, and exit gates were unlocked.

The facility had 2 bathrooms. The resident bathroom contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 11:57 a.m. LPA measured the water temperature in the resident bathroom to be 116.0 degrees Fahrenheit.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. 4 out of 6 residents were watching television together in the living room. Resident files and medications were locked by the dining area. At 12:00 p.m. LPA measured the room temperature to be 77 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food in the kitchen and garage. A facility menu was posted on the refrigerator. Sharps were locked with cleaning solutions in the laundry area. LPA observed an operable washer and dryer near the kitchen.

LPA observed patio furniture in good condition in the back yard. 3 out of 3 gates to the pool were locked. 3 dogs were present in the patio area. The garage was locked and contained surplus food and cleaning supplies.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

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