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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600297
Report Date: 12/01/2021
Date Signed: 12/01/2021 02:40:06 PM

Document Has Been Signed on 12/01/2021 02:40 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:TRUDEZ HOME CAREFACILITY NUMBER:
197600297
ADMINISTRATOR:LOPEZ, VIRGILIOFACILITY TYPE:
740
ADDRESS:25821 OLIVAS PARK ROADTELEPHONE:
(661) 259-1827
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 5CENSUS: 2DATE:
12/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Josefina Paras - StaffTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina met with Josefina Farardo Paras (S1) for a
case management. The purpose of the case management visit was to issue deficiencies observed during today's complaint investigation. Deficiencies observed have nothing to do with complaint.

Entrance interview.

At 10:02 am LPA did not observe transfer request on file for Staff (S1).
At 10:15 am LPA conducted a tour of the facility and interviewed resident who were able to communicate.
At 10:20 am LPA observed a hospice resident in room #2. Facility does not have an approval for hospice.

Following citations issued for the identified deficiencies pursuant to Title 22 Regulations on LIC809D.

Exit interview conducted, appeal rights discussed and a copy of this report provided to the Administrator. `
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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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Document Has Been Signed on 12/01/2021 02:40 PM - It Cannot Be Edited


Created By: Angela Panushkina On 12/01/2021 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197600297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...
This requirement is not met as evidenced by:
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Administrator has agreed to either have the staff get fingerprinted or submit the request for trinsfer. Administrator will provide an updated LIC500 to reflect new staff.
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Based on record review, the licensee did not comply with the section cited above. S1 is not associated to the facility which poses an immediate health, safety risk to persons in care.
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Type A
12/03/2021
Section Cited
CCR87632(a)(1)

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87632 Hospice Care Waiver
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency... (1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time.
This requirement is not met as evidenced by:
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Administrator has agreed to submit a hospice waiver or relocate the resident immediately. Proof of waiver request or relocation address shall be submitted (CCLD) Community Care Licensing Department
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Based on record review, the licensee did not comply with the section cited above. On 11/23/21 licensee accepted a hospice resident. However, the facility did not have an approval for hospice, which poses an immediate health, safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
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