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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610116
Report Date: 01/30/2023
Date Signed: 01/30/2023 02:50:05 PM

Document Has Been Signed on 01/30/2023 02:50 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 HOMEFACILITY NUMBER:
197610116
ADMINISTRATOR:UKWAMEDUA, MARIANFACILITY TYPE:
735
ADDRESS:9856 WOODMAN AVETELEPHONE:
(818) 686-1654
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 0DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Andre FoudaTIME COMPLETED:
02:54 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Annual Required visit to this facility. LPA disclosed to staff the purpose of this visit.

LPA conducted a tour at 1:40 PM the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Smoke alarms and carbon monoxide detectors were present and function properly. The fire extinguisher was observed to be charged.

LPA was escorted to the living and dining combination area and observed adequate seating for residents. Staff confirmed this facility does not currently have any residents residing here. The living area had furnishings and sufficient lighting. The area was clean and well kept. There were also games available for residents use to use.



LPA observed kitchen to be clean and appliances in good repair. The knives, medications and cleaning supplies to be locked in two (2) separate cabinets off or adjacent to staff bathroom. Laundry in kitchen with appliances observed to be in good repair. The first aid kit was present and stocked. LPA observed a locked door which is the staff room.

LPA observed resident bedrooms, bathrooms, personal accommodations, and common areas: all resident bedrooms toured had the required furniture for residents’ comfort and safety. Bedrooms #1 and bedroom #2 designated as non-ambulatory. 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.
(Cont to 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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: 01/30/2023
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( Cont from 809)

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. The water temperature range was between 113.0 and 114.5 degrees Fahrenheit.

In the backyard, a patio table and chairs observed with in good repair with adequate seating. A locked shed observed to have six-month supply of PPE’s.

No Deficiencies cited. Exit interview conducted and reported given



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

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC809 (FAS) - (06/04)
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