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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610116
Report Date: 05/16/2022
Date Signed: 05/16/2022 03:24:59 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
04/27/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220427103525
FACILITY NAME:GOLETA WOODMAN HOMEFACILITY NUMBER:
197610116
ADMINISTRATOR:UKWAMEDUA, MARIANFACILITY TYPE:
735
ADDRESS:9856 WOODMAN AVETELEPHONE:
(818) 686-1654
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY:4CENSUS: 2DATE:
05/16/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tajudeen AsifuTIME COMPLETED:
03:21 PM
ALLEGATION(S):
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Resident not provided proper bedding.
Staff did not allow resident access to facility bathroom.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Tajudeen Asifu.

--- Resident not provided proper bedding.

It was reported that Resident #1 (R1) has been provided a large curtain for bedding. On 05/02/2022 LPA conducted a physical plant tour at around 10:30AM and interviewed one staff and R1 from 11:00 AM - 12:20 PM. During the physical plant tour, LPA observed proper bedding in all bedrooms. During interviews, R1 stated, “I thought it was a curtain, I guess it was the cover for the box spring, I just didn’t like it….”

Based on interviews and observations, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
(Cont. on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20220427103525
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: 05/16/2022
NARRATIVE
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--- Staff did not allow resident access to facility bathroom.

It was reported that facility staff locked the bathroom that is closest to R1’s bedroom, and staff would not allow R1 to use that bathroom. On 05/02/2022 LPA conducted a physical plant tour at around 10:30AM and interviewed one staff and R1 from 11:00 AM - 12:20 PM. During the physical plant tour LPA observed that all restrooms were unlocked. During interviews, R1 stated that they didn’t have access to the restroom “for a little while” and that it was “locked but then they unlocked it.” Interviews with staff also revealed that the restroom was locked during cleaning to avoid injury, that they never clean more than one at a time so there is always at least one restroom available for residents.

Based on interviews and observations, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2