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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610116
Report Date: 08/15/2022
Date Signed: 08/15/2022 02:21:55 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
05/05/2022 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220505153943
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:
08/15/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Andre FoudaTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff sexually assaulted resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 9:40 am. LPA Smith contacted the administrator and disclosed the purpose of the visit. The administrator revealed a staff member (Andre Fouda) will arrive shortly and is authorized to sign report. LPA Smith met with Andre Fouda at 10:20 am and explained the reason for this visit.

It was alleged that client #1 (C1) was sexually assaulted by one of the staff members.
Initial visit was conducted by the Licensing Program Analysts (LPA) Abeye Duguma on 05/06/2022. LPA Duguma conducted a physical plant tour at around 9:30AM. Interviews were conducted with one staff and one resident.

On 05/06/2022 this case was referred to the Community Care Licensing Investigations Branch (IB) and Investigator Brunelli assisted the investigation by interviewing other witness on 05/10/2022.
(Cont. to 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
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-20220505153943
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: 08/15/2022
NARRATIVE
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(Cont. to 9099C)

Per the investigative findings of IB investigator: Client #1 (C1) previously made both false physical and sexual abuse allegations to get rid of caregivers they did not like. C1 had two (2) Right Choice in-home care caregivers (2:1) assigned during the day at the facility and a Right Choice in-home care giver (1:1) assigned overnight 11:30pm-06:30 am. Also, per the interviews conducted, Staff #1 (S1) did not work directly with C1 at any time or provide 1:1 care. C1 also has a history of calling the Suicide Prevention Hotline and Crisis Intervention Team. Based on information revealed from interviews, there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time.

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

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2