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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608844
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:11:43 PM


Document Has Been Signed on 12/21/2022 04:11 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 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:
12/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Rhoda GochinTIME COMPLETED:
04:15 PM
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At 3:20 p.m. on 12/21/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Administrator and disclosed the reason for the visit.

Today’s case management visit pertained to Resident #1 (R1) and their choice to leave or remain at the facility. LPA spoke with the Administrator over the phone about the matter at 4:13 p.m. on 12/19/2022. LPA called R1’s daughter-in-law and Durable Power of Attorney (DPOA) at 3:16 p.m. on 12/20/2022 to obtain more information. Today, LPA attempted to interview R1. The Administrator noted R1 left with family around 1:00 p.m. on 12/20/2022. LPA conducted a record review and interviewed the Administrator at 3:45 p.m. From interview, R1 told the Administrator from 12/17/2022 to 12/20/2022 that they would rather die than leave the facility. The Administrator noted R1's episodes of crying about the issue. From record review, the DPOA was listed as R1's responsible person and emergency contact, however they did not provide documentation of their DPOA status until 12/20/2022. Based on record review and interviews, the Administrator regarded R1's personal rights and choice to remain at the facility until the DPOA discharged R1.

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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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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