197610116-2-8-2022-31-AS-TSMH-CBFUNU-20220208144432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610116
Report Date: 01/28/2022
Date Signed: 02/08/2022 02:44:58 PM

Document Has Been Signed on 02/08/2022 02:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOLETA WOODMAN HOME		FACILITY NUMBER:	197610116
ADMINISTRATOR:	UKWAMEDUA, MARIAN		FACILITY TYPE:	735
ADDRESS:	9856 WOODMAN AVE		TELEPHONE:	(818) 686-1654
CITY:	PACOIMA	STATE: CA	ZIP CODE:	91331
CAPACITY: 4		CENSUS:	DATE:	01/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Administrator, Marian Ukwamedua		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced Annual Required visit to this facility. LPA was greeted by facility staff, Andre Fouda, who were observed wearing a mask and took LPA's temperature upon entry and Covid symptoms questions contained on sign in log for each visitor to complete. LPA informed staff the purpose of this visit. The administrator was called at 10:45 AM and arrived later.

LPA conducted a tour at 12:45 PM of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA was escorted to the living and dining combination area and observed adequate seating for residents. Staff confirmed there are two (2) ambulatory residents. The living area had furnishings and sufficient lighting. There were games for clients to use. The area was clean and well kept.

Smoke alarms and carbon monoxide detectors were present and function properly. The fire extinguisher was current with receipt.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the two (2) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk and eggs observed with juice. The freezer is stocked with meats, poultry, and frozen vegetables. There is one (1) four (4) person Ready America emergency pack supply including a supply of canned foods, dried foods, extra paper towels and water.

The knives, resident’s medications and cleaning supplies were locked in two (2) separate cabinets off or adjacent to staff bathroom. LPA checked first aid kit and the first aid kit has sufficient supplies including a backup first aid kit. LPA observed a locked door which is the staff room

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/28/2022

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(Cont Fom 809)

A tour of the resident bedrooms, bathrooms, personal accommodations, and common areas (all resident bedrooms toured had the required furniture for residents’ comfort and safety). Common areas were observed for the ability to safely serve the needs of residents, including cleanliness, signal system, locks, skid materials, grab bars, and comfortable temperatures. LPA observed a sufficient supply of linens and PPEs in the hall closet.

There are two bathrooms which contain “wash your hands” sign, hand soap, paper towels, and trash cans. The hot water temperature was measured for two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 109.6 and 111.1 degrees Fahrenheit. Facility maintains a comfortable temperature for residents.

Facility grounds were free of hazards. In the backyard, a locked shed has a six-month supply of PPE’s.

LPA reviewed files for the two (2) residing residents. All resident files included current medical assessments, physician orders for medications and centrally stored medication logs. Staff files were also inspected. All staff files inspected had current first aid/ CPR documentation as well as the appropriate training documentation. Medications are given as prescribed.

No Deficiencies cited. Exit interview conducted and report emailed

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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