<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601592
Report Date: 06/07/2021
Date Signed: 06/07/2021 04:27:28 PM

Document Has Been Signed on 06/07/2021 04:27 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:
197601592
ADMINISTRATOR:LOPEZ, VIRGILIOFACILITY TYPE:
740
ADDRESS:23844 VIA JACARATELEPHONE:
(661) 259-7019
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 4DATE:
06/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Virgilio LopezTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced Case Management Deficiencies visit in conjunction with a Initial 10 day complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to address deficiencies that were identified during the complaint investigation visit that is not related to the complaint allegation.

Upon arrival to the facility at 9:00 am LPA conducted a tour of the facility with staff Connie Cipriano. From approximately 9:10 am to 9:20 am LPA conducted interview with Ms. Cipriano. From 9:25 am to 10:00 am LPA conducted review of files for all residents. From 10:00 am to 10:50 am LPA conducted interview with the administrator and observed as administrator counted medications for resident 1 (R1).


  • While conducting a tour of the facility LPA observed Resident 1 (R1's) bed had two half rails placed on the bed next to each other. (Photo taken).
  • LPA observed bed rails non bed for Resident 2 (R2) however licensee does not have order for the rails.
  • While conducting interview with Staff LPA was informed that R1 and R2 are unable to reposition without staff assistance. Both residents are considered bedridden however licensee does not have bedridden fire clearance.
  • Physicians report for 3 residents who have a Major Neurocognitive disorder diagnosis are dated 2019 and physician report for 4th newly admitted resident has not been obtained.
  • Licensee does not have PRN authorization letter for 4 out of 4 residents
  • Staff are not documenting the PRN medications when administered.
  • Staff is crushing medication For R1 and R2 without a doctors order.


Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited: (Refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 06/07/2021 04:27 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 06/07/2021 at 01:23 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: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2021
Section Cited
CCR
87202(a)(2)

1
2
3
4
5
6
7
87202 (a) (2) FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance.
1
2
3
4
5
6
7
Licensee/Administrator will submit an LIC 200, facility sketch and an bedridden plan of operation. The facility sketch will need to specify the room designated for bedridden residents.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on observations made and interview with staff the licensee did not comply with the cited section by retaining two bedridden resident without proper fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Administrator was informed that civil penalties will continue to accrue until POC is completed.
Type A
06/08/2021
Section Cited
CCR87608(a)(5)(B)

1
2
3
4
5
6
7
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator will review the regulation., contact the hospice agency and obtained a current hospice care plan which will indicate the need for the full rail. Licensee will ensure to utilize full rail if order is obtained and not 2 half rails. Copy of the hospice care plans will be submitted as POC.
8
9
10
11
12
13
14
Based on observations made while touring the facility the licensee did not comply with the section cited above by placing two half rails as a full rails for R1 who is on hospice however licensee does not have hospice care plan which indicates the need for the rails. which poses an immediate health, safety & personal rights risk to R1.
8
9
10
11
12
13
14
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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/07/2021 04:27 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 06/07/2021 at 01:31 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: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2021
Section Cited
CCR
87608(a)(3)

1
2
3
4
5
6
7
Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/administrator will contact physicians and obtain orders for the bed rails and submit copies as POC.
8
9
10
11
12
13
14
Based on Records reviewed, observations made the licensee did not comply with the section cited above by not obtaining an order for postural support for 2 out of 4 residents which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
06/18/2021
Section Cited
CCR87705(c)(5)(A)

1
2
3
4
5
6
7
(c) Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator will obtained medical assessments for all residents and complete re-appraisals. Copies of the documents will need to be submitted as POC.
8
9
10
11
12
13
14
Based on LPA record review, the licensee did not comply with the section cited by not obtaining an Annual Medical assessment and not completing annual re-appraisals for 3 out of 4 residents diagnosed with dementia. This poses a potential health and safety risk to the residents in care.
8
9
10
11
12
13
14
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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/07/2021 04:27 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 06/07/2021 at 01:45 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: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2021
Section Cited
CCR
87465(b)(c)(d)

1
2
3
4
5
6
7
Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator will contact residents Physicians to obtain PRN authorization letters for all residents who they provide medication assistance to. Copies of the PRN authorization letters will need to be submitted as POC.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above by not obtaining PRN authorization letters for 4 out of 4 residents which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
06/18/2021
Section Cited
CCR87465(C3)(D3)

1
2
3
4
5
6
7
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will create PRN administration log to be utilized at the facility. A copy of the log with a written statement indicating that PRN logs will be used as necessary for all residents will be submitted as POC.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above by not keeping PRN administration records when given to 3 out of 4 residents poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/07/2021 04:27 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 06/07/2021 at 01:55 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: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2021
Section Cited
CCR
87465(a)(6)(D)

1
2
3
4
5
6
7
(D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/administrator will contact R1 and R2's physicians and obtain an order to crush medications. Copy of the order will be submitted as POC.
8
9
10
11
12
13
14
Based on interview with staff, the licensee did not comply with the section cited above by crushing and camouflaging medications with food without a doctors order for 2 out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021


LIC809 (FAS) - (06/04)
Page: 5 of 5