197608844-3-3-2024-31-AS-JGTN-D2ZRNV-20240303121059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608844
Report Date: 03/03/2024
Date Signed: 03/03/2024 12:11:30 PM

Document Has Been Signed on 03/03/2024 12:11 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
WOODLAND HILLS S.ASC, 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:	03/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Dorcas Baget - Assistant Administrator		TIME COMPLETED:	12:15 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) Gary Tan, met with Assistant Administrator Dorcas Baget for a One (1) year required visit for this facility. A tour of the physical plant was conducted at 9:13 AM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has five (5) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory resident, one of which maybe bedridden on Room #1. Hospice waiver for three (3) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. Smoke detectors were tested and observed to be operational. There is a carbon monoxide detector installed in the facility. There is a fire extinguisher located in the living room and was observed to be full and last inspected on 05/18/23. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The swimming pool is appropriately fenced and observed to be locked. (continued on LIC 9099-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2024

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRIUMPHANT ELDERLY CARE LLC	FACILITY NUMBER: 197608844
	VISIT DATE: 03/03/2024

NARRATIVE

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(continued from LIC 809)

The garage has no access from the inside and was converted into an office and frozen foods storage. Laundry room is located adjacent to the kitchen and was observed to be locked. All the laundry detergents, cleaning solutions, toxins and other chemicals are observed to be locked in a cabinet in the laundry room.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All sharps and knives were also observed to be locked in the laundry cabinet. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. Sink in the bathrooms were removed and under construction. The hot water temperature measured at a range of 163.3°F to 164.1°F Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.

Medications: LPA observed medication was kept in a locked filing cabinet located adjacent to the dining area. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet.

Client records: Client records are reviewed. Residents records appeared to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appear to be complete and updated.

Disaster drill was last conducted on 02/27/24. Required posting are observed to be complete and current and displayed properly at the facility.

Citation issued. Appeal rights discussed and given. Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/03/2024 12:11 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.ASC, 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: 03/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to the hot water temp reached 164.1°F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/03/2024
	Plan of Correction
1 2 3 4	The staff immediately adjusted the water heater and LPA last measured the water temp at 109.9°F. Cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2024

LIC809 (FAS) - (06/04)

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