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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610116
Report Date: 06/20/2022
Date Signed: 06/20/2022 12:19:09 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
05/11/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220511160357
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: 0DATE:
06/20/2022
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Andre FoudaTIME COMPLETED:
12:02 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is isolating resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Andre Fouda.

--- Facility is isolating resident

It was reported that Resident #1 (R1) is being isolated from family by the caregiver. On 05/13/2022, LPA interviewed one staff from 2:00 - 3:00 PM and on 06/20/2022, LPA interviewed the Responsible Party from 10:20 - 10:45 AM. Interviews revealed that staff did not isolate R1 or keep R1 from visiting with family. R1's Responsible Party stated, "We are in good communication with the Administrator there at Goleta Woodman Home and we have never felt that they were trying to keep us from speaking with or seeing each other."

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

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
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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