<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610116
Report Date: 08/01/2022
Date Signed: 08/01/2022 04:09:52 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
03/18/2022 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220318143301
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:
08/01/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Andre FoudaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is out of ratio.
Facility does not allow providers into the home to provide services to resident.
Facility is not providing resident hot meals.
Facility is not providing resident basic self care products.
Facility staff does not adequately supervise resident.
Facility does not provide resident transportation services.
Facility staff did not seek resident ER services.
Facility did not provide resident's responsible party ER discharge paperwork.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lynn Smith made an unannounced complaint visit to this facility at 9:45 am. The main gate to the facility was locked. LPA Smith contacted the administrator and disclosed the purpose of the visit. The administrator revealed a staff member will arrive shortly. LPA Smith met with facility staff at 10:55 am and explained the reason for this visit.

During initial visit, on 03/24/22, LPA Smith conducted tour of bedroom between 2:45-3:15 pm. Requested facility documents relevant to the investigation at 11:35 AM. LPA interviewed staff and Assistant Administrator 11:45 AM to 3:30 PM.
On today’s visit, LPA Smith conducted physical plant tour at 11:50 am and observed no residents are residing at the facility.
Facility is out of ratio
LPA Smith interview with staff and facility files revealed that facility has one (1) administrative staff and one (1)
(Cont to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
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 4
Control Number 31-AS-20220318143301
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: 08/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont from 9099)

direct care staff routinely working in the facility and the facility census is 2 residents.

Based on the information gathered during this licensing visit, and from staff interviews there is insufficient information to verify the allegation. Therefore, the allegation is currently UNSUBSTANTIATED .

Facility does not allow providers into the home to provide services to resident.

It was alleged that the facility does not allow providers into the home to provide services to resident. LPA Smith was unable to interview R1 as R1 no longer resides at facility and location is unknown. LPA Smith interview with staff revealed that R1 had 1:1 service but due to compatibility issues between the provider and resident those services were discontinued and new services pending until another suitable provider available.

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED .

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED.

Facility is not providing resident hot meals.

It was alleged that the facility is not providing hot meals. LPA interview with staff revealed that the facility has a menu posted in the kitchen and on the refrigerator with various hot meal offerings including but not limited to:

Breakfast: Oatmeal, toast, or pancakes with bacon and eggs

Lunch: Beef and bean burrito, soup, or Hot Dogs

Dinner: Steak with Mash potatoes, corn to baked fish or pork chops with rice and beans.

Staff also revealed that R1 is on a vegan diet and they write out their own menu which is posted next to facility menu.

(Cont to 9099C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220318143301
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: 08/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont. from 9099C)

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED.

Facility is not providing resident basic selfcare products.

It was alleged the facility is not providing resident with basic self-care products such as deodorant. During tour of facility on 03/24/22, LPA observed the facility had supply of hygiene items and LPA observed deodorant and other hygiene items in R1 bedroom. Interview with staff revealed that residents are routinely asked if any hygiene products or other items need to be replenished.

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED

Facility staff does not adequately supervise resident.

It was alleged that the facility does not adequately supervise resident. LPA interview with staff revealed that staff present in house continually engages residents throughout the day. The facility also keeps a log for residents to log in or out when leaving the facility.

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED.

Facility does not provide resident transportation services.

It was alleged that the facility does not provide resident transportation services. LPA interview with staff revealed that the admission agreement states what transportation services will be provided which included but not limited to transportation to Airport/train or bus station to visit friend/relatives and transportation to medical or dental appointments which is signed by each resident.

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED.

(Cont to 9099C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220318143301
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: 08/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont from 9099C)

Facility staff did not seek resident ER services.

It was alleged that facility staff did not seek resident ER services. LPA interview with staff revealed that ER services are routinely called for medical emergencies and each call for services is documented on LIC 624 and sent to the Department.

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED.

Facility did not provide resident's responsible party ER discharge paperwork

It was alleged that the facility did not provide resident’s responsible party ER discharge paperwork. LPA interview with staff revealed that after R1 returned to the facility from the hospital R1's mother wanted a copy of the discharged documents. A copy of those documents were provided the same day R1’s mother made a visit to the facility. LPA unable to interview mother due to invalid contact information.

Based on the information gathered during previous licensing visits, and at the time of this visit, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED.


Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4