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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609740
Report Date: 08/06/2023
Date Signed: 08/06/2023 11:58:48 AM

Document Has Been Signed on 08/06/2023 11:58 AM - 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.ASC, 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: 5DATE:
08/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Anabelle Pascua - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Gary Tan, met administrator Anabelle Pascua for a One (1) Year Required visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 8:49 AM and the following was noted:

There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room.

The facility has seven (7) bedrooms and four (4) bathrooms currently occupying five (5) residents. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, of which, one may be bedridden in Room #5 hospice waiver for two (2).

Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the kitchen and observed to be full and last inspected on 05/02/23.
The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740
VISIT DATE: 08/06/2023
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(continued on LIC 809-C)

There is no garage at the facility, only covered three (3) car port located at the back. The backyard has two (2) locked shed being used as a tool shed and old equipment storage. Laundry room is located at the back area by the office and storage rooms. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the storage room. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.



Staff Rooms: Staff room was observed to be locked. No medications are observed in the staff room.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured a range of 108.2°F to 111.3°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the hallway cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits located at the medication cabinet.

Client records: Client records are reviewed. Client records appear to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill was last conducted on 07/05/23. Required posting observed in facility (complaint hot line poster).

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2023
LIC809 (FAS) - (06/04)
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