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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610110
Report Date: 01/27/2025
Date Signed: 01/28/2025 12:08:22 AM

Document Has Been Signed on 01/28/2025 12:08 AM - 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:GOLETA HOMEFACILITY NUMBER:
197610110
ADMINISTRATOR/
DIRECTOR:		UKWAMEDUA, MARIANFACILITY TYPE:
735
ADDRESS:13725 GOLETA STTELEPHONE:
(818) 897-6590
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Marian Ukwamedua, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 1/27/2025 at 1:00PM Licensing Program Analyst (LPA) de la Cerra arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by caregiver, Carol Maruru. Administrator, Marian Ukwamedua was contacted and LPA explained to the administrator the reason for the visit. Administrator arrived shortly thereafter.

This home is designed to operate as a Level 4 Adult Residential Facility (ARF), this facility's fire clearance was approved on 01/13/2020 for four (4) ambulatory developmentally disabled clients.

At approximately 1:30pm LPA and a staff member Tajudeen Asifu, toured the facility and the following was observed. The facility is a single-story building that consist of four (4) bedroom and three (3) bathrooms. The facility maintains a comfortable temperature at 72°F. LPA observed two (2) fire extinguishers, both observed to be fully charged and purchased on 12-07-2024. LPA observed the required facility postings by the entrance hallway. The facility provides a telephone for clients to use and LPA observed the phone to be operational.

LPA observed dual smoke/carbon monoxide detectors that are hard wired and interconnected. Smoke detector was tested @2:15pm and was observed to function properly.

Kitchen Area: The main area kitchen where clients’ meals are prepared was observed to be clean. Appliances were clean and functional. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food and were properly stored. LPA observed knives kept in a locked cabinet, inaccessible to clients. Trash bin has a covered lid. The dining table by the kitchen area had the appropriate table and chairs to accommodate the clients at this facility.

Common Areas: The facility has a common area available for client use. LPA observed the common area is properly furnished with clean furniture and in good repair.. No obstructions and or tripping hazards throughout the common area.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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: GOLETA HOME
FACILITY NUMBER: 197610110
VISIT DATE: 01/27/2025
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Bedrooms: There are four (4) bedrooms designated for client use. All bedrooms are furnished with a night stand, a chair, a lamp, a chest of drawers, a closet and a bed with clean bedding and linens. All bedrooms have sufficient closet space and have sufficient lighting.

Bathrooms: LPA observed three (3) bathrooms that are clean and in good repair. LPA observed the functional and appropriate fixtures. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 112°- 118°F. LPA observed the appropriate grab bars by the toilet and in the shower areas. LPA also observed non-skid mats in all the shower areas.

Laundry Area: LPA also observed the washer and dryer located outside the kitchen area which appears to be in good condition. LPA also observed a locked cabinet that stores laundry detergents and some cleaning solutions,

Surrounding grounds: No bodies of water was observed. LPA observed the backyard free from obstructions. A seating area with shade was available for clients to use. LPA observed a locked shed which is inaccessible to clients and it is used as an additional storage for supplies and clients' personal items.

Facility Records: At 2:45PM LPA conducted review of clients’ records and staff records.

LPA reviewed four (4) out four (4) client records and two (2) staff records to ensure compliance. The facility files were kept in locked cabinet located in the kitchen area.

Medications: The medications were kept in locked cabinet in the kitchen area and is inaccessible to clients in care. The first-aid kit is complete.

At approximately 3:30PM medications and medication records were reviewed for proper documentation. Centrally Stored Medication Records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR). LPA reviewed client's P&I records.

Administrative: LPA collected a copy of Certificate of Liability Insurance effective until 03/03/25, copy of Surety Bond effective until 01/21/2026, LIC500 and LIC9020.

No deficiencies cited during today's visit. Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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