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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610116
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:49:55 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
03/23/2022 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220323121510
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: DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:TIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Staff are verbally abusing resident in care.

Facility did not provide resident with adequate shoes.

Facility is not meeting resident’s hygiene needs.

Staff hit resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lynn Smith made a complaint visit to this facility at 9:30am. Due to no staff currently working at the facility, 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 Andre Fouda at 10:05 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 between 11:45 AM to 3:30 PM.
On today’s visit, LPA Smith conducted physical plant tour at 10:50 am and observed no residents are residing at the facility.

Staff are verbally abusing resident in care
It was alleged that staff are verbally abusing resident in care including emotionally and mentally abusing (Cont to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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 3
Control Number 31-AS-20220323121510
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: 08/04/2022
NARRATIVE
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(Cont from 9099)

Resident one (R1). LPA Smith was unable to interview (R1) as no longer resides at facility and location is unknown. LPA interview with staff revealed that staff interaction with R1 was limited. Staff revealed that R1 spent majority of time interacting with assigned (24-hour) 1:1. The assigned provider documents activities, problem behavior and other incidents related to R1 in service binder. LPA reviewed 1:1 service binder documents and no incidents of verbal, emotional or mental abuse from staff documented. Staff revealed that R1s 2:1 (24-hour provider) was present from date of admission to facility on:01/06/22. Staff also revealed R1s 2:1 changed March 1st, 2022 to a 1:1.

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 with adequate shoes

It was alleged the facility did not provide R1 with adequate shoes. Interview with staff revealed that residents are routinely asked and checked if additional clothing and shoes are needed and purchases were made based on residents’ needs. Due to problems with R1’s SSI funds, the facility did not receive Personal and Incidental (P&I) funds for R1 since admission. Therefore, the staff was unable to purchase any clothing or shoes for the R1. Staff also revealed that while in the facility R1 had clothing and shoes to wear. During tour of facility on 03/24/22, LPA observed two pair of functional shoes in R1 bedroom.

Based on interviews and observation, there is lack of pertinent information to support the allegation. Therefore, the allegation is currently UNSUBSTANTIATED

Facility is not meeting resident’s hygiene needs

It was alleged the facility is not meeting R1 hygiene needs. During tour of facility on 03/24/22, LPA observed the facility had supply of hygiene items and LPA observed large shampoo/conditioner bottle in R1’s individual container for hygiene supply. Interview with staff revealed that residents are routinely asked if any hygiene products need to be replenished.

Based on interviews and observation, 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: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220323121510
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: 08/04/2022
NARRATIVE
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(Cont from 9099C)

Staff hit resident

It was alleged that staff hit resident. LPA interview with staff revealed that staff interaction with R1 was limited. Staff revealed R1 spent majority of day and night interacting with assigned (24-hour) 1:1 provider. LPA reviewed service binder documents and no incidents of staff hitting R1 documented.

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.

No other issues noted during this visit.

Exit interview conducted. Copy of this report issued.

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

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3