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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609740
Report Date: 05/23/2022
Date Signed: 05/23/2022 12:57:38 PM

Document Has Been Signed on 05/23/2022 12:57 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:TRACY'S BOARDING CARE - LASSENFACILITY NUMBER:
197609740
ADMINISTRATOR:MATHEW, THRESIAMMAFACILITY TYPE:
740
ADDRESS:17419 LASSEN STTELEPHONE:
(818) 882-4930
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Thresiamma Mathew TIME COMPLETED:
01:10 PM
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On 05/23/22 at 11:30 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with designee Administrator Anabelle Pascua and then with Administrator Thresiamma Mathew. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 11: 35 a.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. LPA was asked to sing in and staff conducted a covid screening upon arrival. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 11:49 a.m. and appear to be functional. Fire extinguisher has a purchase date of 04/11/2022. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 72.0 F. Medication are centrally stored in a closet located in the hallway. Resident Rooms: Facility has seven (7) bedrooms which of six (6) are designated for resident use. Facility has two live-in staff. All seven (7) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting.

Continue on 809-D

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740
VISIT DATE: 05/23/2022
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Bathrooms: There are four (4) bathrooms in the facility of which three (3) are designated for resident’s use. LPA observed all bathrooms to be clean and free of any hazards. The hot water was tested and measured 113.7 F, which is in regulation. All trash cans located in the bathrooms had tight fitting lids. There is an attached storage area that is used for storage of food and a laundry area. Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a shack located outside that is used for additional storage. There are no bodies of water.

No deficiency cited. Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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