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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609740
Report Date: 03/04/2025
Date Signed: 03/04/2025 11:19:38 AM

Document Has Been Signed on 03/04/2025 11:19 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:
03/04/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Anabelle PascuaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 03/04/25, at 9:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, Plan Of Correction (POC) and was greeted by Administrator, Anabelle Pascua. The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 10/16/2024.


At 10:15 AM LPA toured the facility and requested the following:

LPA interviewed staff to determine if there was an updated staff roster showing that a staff works during the night shift which has not been sent to the LPA. There is five (5) dementia residents that reside at the above facility which requires night supervision. LPA has not received any Unusual Incident/Injury reports regarding any of the residents being sent to the hospital and/or injuries. From the previous report on 10/16/24, there was one resident, 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-Community Care Licensing Department.

LPA cleared the POC that required postural support. There is no residents requiring postural support at this time.

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

Two (2) citations will be issued on 809-D for non-reporting to CCLD and for no night supervision which is required for dementia residents.

An exit interview was conducted, citation(s) were issued, appeals rights and a copy of this report was given to the administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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Document Has Been Signed on 03/04/2025 11:19 AM - It Cannot Be Edited


Created By: Gina Saucedo On 03/04/2025 at 10:21 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: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2025
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 Due Date: 03/12/25
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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
03/12/2025
Section Cited
CCR87705(e)(5)

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87705 Care of Persons with Dementia
(e) Licensees..5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating.. Personal Rights of Residents in All Facilities.. Additional Personal Rights of Residents in Privately Operated Facilities.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.

POC Due Date: 03/12/25
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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: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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