197610116-2-13-2025-31-AS-LDLC-DDV9WT-20250213224425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610116
Report Date: 02/13/2025
Date Signed: 02/13/2025 10:45:12 PM

Document Has Been Signed on 02/13/2025 10:45 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOLETA WOODMAN HOME		FACILITY NUMBER:	197610116
ADMINISTRATOR/ DIRECTOR:	UKWAMEDUA, MARIAN		FACILITY TYPE:	735
ADDRESS:	9856 WOODMAN AVE		TELEPHONE:	(818) 686-1654
CITY:	PACOIMA	STATE: CA	ZIP CODE:	91331
CAPACITY: 4		CENSUS: 3	DATE:	02/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Nusifa Bahingire,Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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On 2/13/2025, Licensing Program Analyst (LPA) de la Cerra arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by caregiver, Hanifah. Administrator, Nusifa Bahingire was contacted and LPA explained to the administrator the reason for the visit. Administrator arrived shortly thereafter.

This home is designed to operate as a Level 4G Adult Residential Facility (ARF), this facility's fire clearance was approved on 11/13/2020 for four (4) ambulatory developmentally disabled clients.

At approximately 10:30AM LPA and a staff member Hanifa, toured the facility and the following was observed. The facility is a single-story building that consist of five (5) bedrooms and two (2) bathrooms. The facility maintains a comfortable temperature at 74°F. LPA observed one (1) fire extinguishers, observed to be fully charged and purchased on 12-07-2024. LPA observed the required facility postings by the entrance bedroom hallway. The facility provides a telephone for clients to use and LPA observed the phone to be operational.

LPA observed dual smoke/carbon monoxide detectors that are hard wired and interconnected. Smoke detector was tested @11:45pm and was observed to function properly.

Kitchen Area: The main area kitchen where clients’ meals are prepared was observed to be clean. Appliances were clean and functional. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food and were properly stored. LPA observed knives kept in a locked cabinet by the laundry area, inaccessible to clients. Trash bin has a covered lid. The dining table by the kitchen area had the appropriate table and chairs to accommodate the clients at this facility.

Common Areas: The facility has a common area available for client use. LPA observed the common area is properly furnished with clean furniture and in good repair. No obstructions and or tripping hazards throughout the common area.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLETA WOODMAN HOME	FACILITY NUMBER: 197610116
	VISIT DATE: 02/13/2025

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Bedrooms: There are five (5) bedrooms, one (1) is used as an office and four (4) are designated for client use. All four (4) bedrooms are furnished with a night stand, a chair, a lamp, a chest of drawers, a closet and a bed with clean bedding and linens. All bedrooms have sufficient closet space and have sufficient lighting.

Bathrooms: LPA observed two (2) bathrooms that are clean and in good repair. LPA observed the functional and appropriate fixtures. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 106°- 109°F. LPA observed the appropriate grab bars by the toilet and in the shower areas. LPA also observed non-skid mats in all the shower areas.

Laundry Area: LPA also observed the washer and dryer located in the kitchen area and both machines appear to be in good condition. LPA also observed a locked cabinet that stores laundry detergents and some cleaning solutions,

Surrounding grounds: No bodies of water was observed. LPA observed the backyard free from obstructions. A seating area with shade was available for clients to use. LPA observed a locked shed which is inaccessible to clients and it is used as an additional storage for supplies and clients' personal items. There is a detached locked garage at the back side of the premises and it is used for storage.

Facility Records: At 12:05PM LPA conducted review of clients’ records and staff records.

LPA reviewed three (3) out three (3) client records and two (2) staff records to ensure compliance. The facility files were kept in locked cabinet located by the kitchen area.

Medications: The medications were kept in locked cabinet in the kitchen area and is inaccessible to clients in care. The first-aid kit is complete.

At approximately 12:45PM medications and medication records were reviewed for proper documentation. Centrally Stored Medication Records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR). At 1:00PM LPA reviewed client's P&I records.

Administrative: LPA collected a copy of Certificate of Liability Insurance effective until 03/03/25, copy of Surety Bond effective until 03/03/2025, LIC500 and LIC9020.

No deficiencies cited during today's visit. Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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