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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610116
Report Date: 01/30/2026
Date Signed: 01/30/2026 01:33:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/30/2026 01:33 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLETA WOODMAN HOMEFACILITY NUMBER:
197610116
ADMINISTRATOR/
DIRECTOR:		UKWAMEDUA, MARIANFACILITY TYPE:
735
ADDRESS:9856 WOODMAN AVETELEPHONE:
(818) 686-1654
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 3DATE:
01/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Nusifa Bahingire-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. Upon their arrival, staff on duty were Flavia Nampiima and Nusifa Bahingire - Administrator. LPA explained the purpose of the visit. The program is vendorized through the North Los Angeles Regional Center. The Adult Residential Facility (ARF) is licensed for four (4) ambulatory developmentally disabled adults, ages 18 through 59; current census is three (3) clients.

LPA toured the facility with the Administrator at 9:50 am and observed the following:



Required postings were observed in the hallway/den area. The building is an one story house, on a busy street. The physical plant appeared clean, sanitary, with no visible immediate hazards. There are three (3) exit doors. The front entry is the main exit door and the secondary exit door is located in the hallway/den, leading to the backyard. There is one fully charged fire extinguisher in the kitchen, purchased on 12/22/2025. Facility conducts quarterly fire and safety drills. The last fire drill was conducted on 12/03/2025 and the last earthquake drill was conducted on 09/03/2025. Smoke/carbon monoxide detectors are hard wired and interconnected. Smoke/carbon monoxide detectors were tested at 10:05 am and was observed to function properly. Exterior security cameras were installed in the front and rear area. Facility offers a land-line telephone, cable and internet access. for clients' use.

Common Areas: Include a hallway/den, living room and dining room. The common areas were properly furnished with ample sitting/tables for appropriate number of clients. Television set and activity/gaming areas were observed in the living room.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 WOODMAN HOME
FACILITY NUMBER: 197610116
VISIT DATE: 01/30/2026
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Kitchen/Laundry Room: The kitchen appliances consisted of a refrigerator, stove, and microwave and the fixtures were observed to be functional. All food processing surfaces were clean and sanitary. Knives, cutlery and sharp kitchen objects are stored in locked cabinet in the laundry room. Laundry machines were located next to the kitchen. All detergents and toxins are stored in locked cabinets, inside the laundry room, inaccessible to clients in care. LPA found a sufficient supply of perishable food items (2 days) and non-perishable food (7 days) supplies, with sufficient amount of dishes for the census of four (4).

Bathrooms: There are two (2) bathrooms designated for staff and residents’ use. All toilets and sinks are maintained in sanitary, operating condition. One of the bathrooms is located near the laundry room and the other one is located in between bedrooms #1 and #2. LPA observed proper grab bars and non-skid mats in both bathrooms. Hot water temperature was measured at 107.7 and 108.0 degrees Fahrenheit.

Bedrooms: There are five (5) private bedrooms but bedroom #4 is used as a staff room and bedroom #5 is currently used as the office. All clients bedrooms were properly furnished with appropriate chairs, beddings. television sets, linens with sufficient lighting. Bedroom #2 has it's own exit door, leading to the backyard.

Surrounding Grounds: Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. No bodies of water were observed at the facility. There is ample patio space for outdoor activities. Outdoor furniture consisted of a table, chairs and umbrella, sufficient for all clients. There is a locked shed and a detached garage, both currently used as storage spaces.

Client Records: The client files were kept in a locked cabinet located in the hallway/den area. LPA reviewed three (3) out three (3) client records to ensure compliance of required documents. The medications and first aid kit/first aid manual, were kept in a locked cabinet in the laundry room, and are inaccessible to clients in care. The medications and medication records for all three (3) clients were reviewed for proper documentation and medications were counted for all three (3) clients. At 12:50PM LPA reviewed P&I counts and records for two (2) of the clients but the third client's P&I is handled by their family.

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NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
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 WOODMAN HOME
FACILITY NUMBER: 197610116
VISIT DATE: 01/30/2026
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Staff Files: Staff files were reviewed in random, to ensure all forms and training certificates are up to date.

Administrative Documents: LPA collected LIC500 and LIC9020 a copy of Certificate of Liability Insurance effective until 03/03/2026 and Surety Bond effective until 05/31/2029. Administrator Certificate is valid until 08/12/2026.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during today's visit.

Exit Interview Conducted / A Copy of the Report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC809 (FAS) - (06/04)
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