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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609740
Report Date: 10/08/2024
Date Signed: 10/08/2024 12:41:09 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20241007141113
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:
10/08/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Thresiamma MathewTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff does not ensure bathroom supplies are made available for residents and residents guests
INVESTIGATION FINDINGS:
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On 10/08/24, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Caregiver Masoledad Calantog. LPA disclosed the purpose of the visit and was able to meet with the administrator about thirty (30) minutes after arrival. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint.

The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:45am, LPA toured the physical plant.

9099-continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20241007141113

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:
10/08/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Thresiamma MathewTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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9
Staff does not ensure residents are allowed to have visitors
INVESTIGATION FINDINGS:
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13
On 10/08/24, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Caregiver Masoledad Calantog. LPA disclosed the purpose of the visit and was able to meet with the administrator about thirty (30) minutes after arrival. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint.

The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:45am, LPA toured the physical plant.

9099-continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20241007141113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/08/2024
NARRATIVE
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This is an amended copy of the report previously issued on 10/08/2024. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same.

Regarding the allegation: Staff does not ensure residents are allowed to have visitors. It is being alleged that a visitor was asked to not visit the facility anymore. LPA interviewed three (3) staff out of four (4) staff that confirmed that the visitors do not stay long when the residents receive visits. Furthermore, Three (3) out of the four (4) staff confirmed that the visitors they do get at the above facility do not interfere with their work duties and/or tell them what to do. Three (3) staff confirmed that the administrator told them not to let certain visitors enter the above facility. LPA was able to observe that two (2) visitors arrived and visited approximately an hour and left. LPA was only able to interview one (1) out of (5) five residents. One (1) resident confirmed that they are doing well and have no issues at the above facility. Therefore, based on the LPA's observations, staff and resident interviews the above allegation(s) above is SUBSTANTIATED at this time.

An exit interview was conducted, a citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator and appeals right.

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

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20241007141113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1-Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met by:
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The Licensee/Administrator
will allow all visitors to visit the above facility unless there is a health and safety issue and is to notify LPA Saucedo immediately if this occurs.

POC 10/09/24
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Based on the observations and interviews the licensee did not ensure one
out of five residents at the above facility to receive visitation rights which poses an
immediate Health, Safety or Personal Rights risks to person 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20241007141113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/08/2024
NARRATIVE
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This is an amended copy of the report previously issued on 10/08/2024. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same.

Regarding the allegation: Staff does not ensure bathroom supplies are made available for residents and residents guests. It is being alleged that the bathrooms do not have any soap for anyone to wash their hands and also no paper towels to dry their hands. During LPA's tour, LPA toured four (4) bathrooms and all four (4) bathrooms had soap and towels to dry hands. LPA interviewed four (4) staff and all four (4) staff confirmed that there is soap and towels in all the bathrooms. LPA was only able to interview one (1) out of (5) five residents. One (1) resident confirmed that there is soap and towels in the bathrooms. Therefore, based on the LPA's observations, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time.

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

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

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5