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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609742
Report Date: 08/10/2021
Date Signed: 08/10/2021 11:39:46 AM

Document Has Been Signed on 08/10/2021 11:39 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TRACY'S BOARDING CARE - LOUISEFACILITY NUMBER:
197609742
ADMINISTRATOR:MATHEW, THRESIAMMAFACILITY TYPE:
740
ADDRESS:10038 LOUISE AVETELEPHONE:
(818) 280-3578
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
08/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Thresiamma MathewTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to complain # 31-AS-20210809091844.

At approximately 9:15 a.m. LPA arrived at the facility and was greeted by staff and allowed entry. LPA observed that Staff #1 (S1) and Staff #2 (S2) were in the process of changing/ bathing Resident 1 (R1). LPA asked S1 if R1 had any wounds and they said "no, just colostomy." LPA asked R1 if they had any wounds and they said that they "have some wounds on [their] butt."

At 10:45 am LPA asked administrator if staff were providing any wound care or colostomy care to R1 and they said "No, only I or home health provide colostomy care." Administrator denied that R1 had any pressure injuries at this time. LPA asked if there were any Home Health records for either wound care or colostomy care and she said "no, everything is digital now with them."

At 10:50 am LPA observed the facility's care notes for R1 on 8/3/21 to indicate that R1 has a "bedsore stage 2."


Report reviewed, signed and delivered. Exit interview conducted, deficiencies on 809D.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
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 2
Document Has Been Signed on 08/10/2021 11:39 AM - It Cannot Be Edited


Created By: Alexander Pitz On 08/10/2021 at 11:09 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 - LOUISE
FACILITY NUMBER: 197609742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2021
Section Cited
CCR
87609(B)(4)

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87609(B)(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).

This requirement is not met as evidenced by:
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Administrator will provide proof of a Home Health agreement being in place for R1
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Based on observations and interviews, the facility did not ensure that a written record of the Home Health agreement for wound care of R1 was kept at the facility which poses an immediate risk to residents in care.
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Type A
08/17/2021
Section Cited
CCR87621(b)(1)(B)

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87621(b)(1)(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of facility staff who have been instructed.

This requirement is not met as evidenced by:
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Adminsitrator will provide proof of an appropriate written care plan being developed by the facility and an appropriately skilled professional.
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Based on observations and interviews, the facility did not ensure that written documentation of the colostomy care being provided by Home Heatlh was kept on file which poses an immediate risk to 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:Eva Miller
LICENSING EVALUATOR NAME:Alexander Pitz
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2021


LIC809 (FAS) - (06/04)
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