197610116-12-28-2021-31-AS-EMIR-CFDLB6-20220614083609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610116
Report Date: 12/28/2021
Date Signed: 12/28/2021 02:35:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20211220152023

FACILITY NAME:	GOLETA WOODMAN HOME		FACILITY NUMBER:	197610116
ADMINISTRATOR:	UKWAMEDUA, MARIAN		FACILITY TYPE:	735
ADDRESS:	9856 WOODMAN AVE		TELEPHONE:	(818) 686-1654
CITY:	PACOIMA	STATE: CA	ZIP CODE:	91331
CAPACITY:	4	CENSUS: 2	DATE:	12/28/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Marian Ukwamedua		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility staff failed to provide adequate food service.
Administrator is disrespectful towards clients.

INVESTIGATION FINDINGS:

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An unannounced initial 10 day complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with staff Cajudeen Asifu. Administrator Marian Ukwamedua arrived to the facility approximately 12:30 pm.

During today's visit from approximately 11:20am to 12:00pm LPA conducted review of 2 client files. From approximately 12:01pm to 12:10pm LPA conducted review of the facility food supply and observed as staff was preparing lunch. From approximately 12:11pm to 1:30pm LPA conducted interview with caregiver, 1 client and the administrator.

Regarding the Allegation of: Facility staff failed to provide adequate food service it was reported that staff overcook, burn the food they cook. It was also reported that the licensee does not assist clients with their preferred diets. When interviewed client 2 (C2) denied that the food staff prepare is overcooked or burned. Per administrator she has not received any complaints about food preparation or anything food related from the clients. Administrator also informed the LPA that they will try to meet the clients with their preferred diet requests

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211220152023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 WOODMAN HOME	FACILITY NUMBER: 197610116
	VISIT DATE: 12/28/2021

NARRATIVE

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Administrator also informed the LPA that they will create personalized menu with the clients to ensure that they provide them meals of their choosing. During todays visit LPA observed personalized menu for client 1 (C1) written by C1 placed on the refrigerator. Also during the visit LPA observed sufficient supply or perishable foods at the facility to include but not limited to packaged salad, fruit and vegetables, frozen meat. LPA also observed that the lunch prepared by staff was properly cooked. Records reviewed revealed that neither client had orders from a physician to be on a special diet.

Based on observations, record reviews and interviews conducted the allegation is Unsubstantiated at this time.

Regarding the allegation of: Administrator is disrespectful towards client it was reported that the administrators communication style with clients is not proper. It was also reported that the administrator does not allow clients to speak and often speaks over clients. Prior to this visit LPA conducted interview with the complainant. During todays visit LPA conducted interview with client 2 (C2) and the administrator. Client 1 was not at the home during the visit to be interviewed. When interviewed C2 denied that the administrator spoke to him or any other client disrespectfully, denied the administrator not allowing him to speak or speaking over him. The Administrator also denied speaking disrespectfully with/to any client. According to the administrator she is available to speak to the clients anytime they want. Administrator also stated that when a client is speaking with her she will listen, wait for them to finish and respond accordingly.

Based on the information obtained from the interviews conducted the allegation is Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

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