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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609740
Report Date: 10/16/2024
Date Signed: 10/16/2024 10:51:56 AM

Document Has Been Signed on 10/16/2024 10:51 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: 6DATE:
10/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Anabelle PascuaTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
NARRATIVE
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On 10/16/24, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced case management visit and was greeted by Administrator, Anabelle Pascua.

LPA was advised that incidents reports were not being sent to Community Care Licensing Department-(CCLD). While conducting staff interviews and record review, LPA discovered that resident #1 (R1) had received two (2) seizures, 911 was called and transported to the hospital. On one (1) of the seizure incidents, R1 had fallen from their wheelchair and none of these incidents were reported and/or sent to CCLD. In addition, R1 has a postural support that does not have a prescription and/or authorized by a doctor. During LPA’s physical tour, LPA observed roaches crawling on the wall of the above facility. Previously LPA has asked for the staff roster showing that a staff works during the night shift and it has not been sent to the LPA. Furthermore, there is dementia residents at the above facility that need night supervision.



Per the California Code of Regulations, Title 22, Division 6, Chapter 8 cited and noted on LIC 809D.

Exit interview conducted, four (4) citation(s) given, appeal rights and copy of report signed and delivered to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 3
Document Has Been Signed on 10/16/2024 10:51 AM - It Cannot Be Edited


Created By: Gina Saucedo On 10/16/2024 at 09:40 AM
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: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2024
Section Cited
CCR
87211(a)(1)(A)

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87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by:
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An Unusual Report is to be sent to Community Care Licensing Department within seven (7) days regarding a death report and/or resident injuries/hospitalizations while in care.
POC 10/30/24
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Based on the LPA observation and interviews the licensee/administrator did not ensure resident reports to be submitted to CCLD from the above facility involving multiple incidents which poses a potential Health, Safety or Personal Rights risks to persons in care.
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Type B
10/16/2024
Section Cited
CCR87608(a)(3)

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A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
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The Licensee/Administrator will contact resident physicians to obtained required medical documentation for postural supports.

POC due date:10/30/24
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Based on observation the licensee failed to ensure that Resident has a written order for postural support placed in Residents file. This poses an immediate health and safety risk to the residents 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.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/16/2024 10:51 AM - It Cannot Be Edited


Created By: Gina Saucedo On 10/16/2024 at 09:47 AM
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: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:

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The administrator/Licensee must at all times keep a facility free of roaches. The administrator/licensee is to show proof of pest control service/documentation and send to LPA by POC 10/30/2024
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Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have a clean and sanitary facility including rooms, common areas clean of roaches thus ensuring the facility was clean, which poses a potential Health, Safety or Personal Rights risks to persons in care.
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Type B
10/16/2024
Section Cited
CCR8705(c)(4)(A)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care...safety and health care needs… (A) In addition to... specified in Section 87415, Night Supervision, a facility with fewer than 16...at least one night staff person...This requirement is not met as evidenced by:
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The licensee/admnistrator will send the LPA an updated personnel report showing the caregivers schedule showing there is a night person on duty seven (7) days out of the week to care for residents with dementia.
LPA by POC 10/30/2024
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Based on the observation, interviews and
record reviews, the licensee did not ensure one out of three staff at the facility to be on duty at night and supervise the care of the residents of dementia have which poses a potential 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.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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