197610110-1-30-2023-31-AS-TSMH-CNKT8L-20230130133032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610110
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:30:37 PM

Document Has Been Signed on 01/30/2023 01:30 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:	GOLETA HOME		FACILITY NUMBER:	197610110
ADMINISTRATOR:	UKWAMEDUA, MARIAN		FACILITY TYPE:	735
ADDRESS:	13725 GOLETA ST		TELEPHONE:	(818) 897-6590
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY: 4		CENSUS: 4	DATE:	01/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Naomi Bahingire		TIME COMPLETED:	01:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Annual Required visit to this facility. LPA's temperature taken upon entry and Covid symptoms questions contained on log. The administrator was contacted and authorized staff to sign.

LPA conducted a tour at 9:55 am of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA was escorted to the living areas. The living and dining room combination area observed to have adequate furnishings, sufficient lighting and observed to be clean with adequate seating for residents.

LPA was escorted to kitchen area. The area was clean and well kept. The kitchen food supply was observed and sufficient for the four (4) residents. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats, poultry, and frozen vegetables. There is a supply of canned foods, dried foods, and water in kitchen panty.

The knives and resident’s medications are locked in separate cabinets in the kitchen. The cleaning supplies were locked in a cabinet outside next to laundry area. LPA checked first aid kit and the first aid kit has sufficient supplies including a backup first aid kit. LPA observed locked staff room.

There are four (4) bedrooms designated for residents. All bedrooms were clean, properly furnished and had sufficient lighting. There were two (2) bathrooms with one (1) designated for residents. Each bathroom has posted “wash your hands” signs and were clean, properly supplied and had functional fixtures. The water temperature range between 106.7- and 107.9-degrees Fahrenheit. Facility maintains a temperature of 70 degrees Fahrenheit for residents.

Smoke alarms and carbon monoxide detectors were present and function properly.

(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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: GOLETA HOME	FACILITY NUMBER: 197610110
	VISIT DATE: 01/30/2023

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(Cont from 809)

There are two (2) fire extinguishers one (1) in kitchen attached to wall and one (1) in hallway attached to wall were both observed to be charged

The backyard has a patio. The covered patio observed to be clean and furnished with adequate seating for residents. A locked shed in the backyard has a six-month supply of PPE’s.

The grounds entry/exits area were clean with and free of obstruction.

No Deficiencies cited.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report given

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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