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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609740
Report Date: 04/27/2024
Date Signed: 04/27/2024 11:06:50 AM

Document Has Been Signed on 04/27/2024 11:06 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TRACY'S BOARDING CARE - LASSENFACILITY NUMBER:
197609740
ADMINISTRATOR/
DIRECTOR:		MATHEW, THRESIAMMAFACILITY TYPE:
740
ADDRESS:17419 LASSEN STTELEPHONE:
(818) 882-4930
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
04/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Thresiamma MathewTIME VISIT/
INSPECTION COMPLETED:
11:27 AM
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On 04/27/24 at 8:25AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Anabelle Pascua and disclosed the purpose of the visit. Thresiamma Mathew the licensee arrived about forty (40) minutes later.

LPA asked for the census, resident, and staff files.


A physical tour was conducted at 9:40 AM and observed the following:



The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. There is one (1) refrigerator and one (1) pantry area with extra food. The kitchen area was clean at the time of the tour. Under the kitchen sink the knives and chemicals are kept locked and inaccessible to the residents. On your right-hand side of the kitchen the fire extinguisher is located fully charged with an expiration date of May 2024.

Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does has a signal system. The facility does not have a pool or any bodies of water. The outside/backyard can be accessed from the dining/living room area and hallway area. There is two sheds in the backyard with resident property and extra wheelchairs and bedding. The washer and dryer are located outside in the backyard. By the washer and dryer there are two doors where there is access to one (1) storage area and one (1) office.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2024
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: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740
VISIT DATE: 04/27/2024
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Bedrooms: There are seven (7) bedrooms and four (4) bathrooms. Two (2) of the seven (7) bedrooms have private bathrooms. One (1) of the seven (7) bedrooms is used as a staff room. There are six (6) resident's rooms, one (1) is currently vacant. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 115-118-degree Fahrenheit. There is extra linen in the hallway.

The medication is locked and inaccessible to the residents in the hallway on the top shelf. The first aid is kept under the medication shelf also in the hallway.

The dining/living room area has enough seating for the residents and the staff. The dining room area has a television, internet access and a telephone.

The house temperature is at 75-degree Fahrenheit.

There are several smoke detectors/carbon monoxides (dual) in the dining/living area that are operable.



Administrative: There is an annual fee that is due by June in the amount of $495.00. At the entrance of the facility on your right-hand side there is door with extra PPE items, administrator License certificate, Yes, Emergency/Disaster Plan, Home Rules and Rights of Individuals, Theft and Loss Policy, Emergency Contacts and the surety bond is updated.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2024
LIC809 (FAS) - (06/04)
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