197608844-12-16-2024-31-AS-LNCA-DC27SS-20241216205534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608844
Report Date: 12/16/2024
Date Signed: 12/16/2024 08:55:58 PM

Document Has Been Signed on 12/16/2024 08:55 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TRIUMPHANT ELDERLY CARE LLC		FACILITY NUMBER:	197608844
ADMINISTRATOR/ DIRECTOR:	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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Rhoda Gochin- Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. At 12NN was greeted by Abigail Gochin and LPA and advised the reason of the visit. At 12:33PM Rhoda Gochin who is the Licensee arrived and was advised the reason of the visit. At 12:08 PM, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the living room. The charge date is 5/9/2024. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents, one of which may be bedridden in room #1; hospice waiver is approved for three (3). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the laundry area. Bedrooms: There were five (5) bedrooms in the facility, three (3) bedrooms are designated for residents' use. Bedroom #1, bedroom #2, and bedroom #3 are all shared bedrooms. The bedrooms are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRIUMPHANT ELDERLY CARE LLC	FACILITY NUMBER: 197608844
	VISIT DATE: 12/16/2024

NARRATIVE

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Bathrooms: There are two (2) bathrooms in the facility designated for residents' and staff use. The bathrooms were properly supplied and has functional fixtures. Hot water temperature was measured at 117.4 degrees Fahrenheit for bathroom #1 located by the entrance of the facility. Bathroom #2 is located in the hallway that is for residents. Hot water temperature was measured at 118.6 degrees Fahrenheit for bathroom #1 located by the entrance of the facility. There was enough clean linen available in the cabinets in the hallway.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Office is located beside the dining area.
Fireplace is centralized. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage detached and is used for storage and staff refrigerator.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRIUMPHANT ELDERLY CARE LLC	FACILITY NUMBER: 197608844
	VISIT DATE: 12/16/2024

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Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Medications and supplements for S1, and residents were seen in an unlock laundry and residents room in an unlock drawer which is accessible to residents. Deficiency will be cited in LIC 809-D.
Resident records were reviewed for requirements and legibility: LPA reviewed all of the client’s files for current appraisal for the residents. Liability insurance a copy was handed to LPA. Planned activities are offered. Residents has missing preplacements appraisals and LIC 613 needs to be signed. LPA observed some forms were not signed or filled. Technical Violation (TV) will be given. Licensee needs to ensure pre-placement appraisal and LIC 613 needs to be filled and signed.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/16/2024 08:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 S1, R4 and R6 medication was accessible which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Medications and supplements needs to be locked and and inaccesible to residents.

Section Cited

When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 6 out of 6 CSMDR which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Licensee needs to have CSMDR for every client, not a pharmacy rx list.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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