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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609742
Report Date: 06/19/2022
Date Signed: 06/19/2022 02:13:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/09/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210809091844
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: 6DATE:
06/19/2022
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Annabel Pascua - Assistant AdministratorTIME COMPLETED:
11:50 PM
ALLEGATION(S):
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Resident developed an unstageable pressure injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with the Assistant Administrator Annabel Pascua and explained the reason for today’s visit.

During the initial visit on 08/10/2021 at 9:15 AM, LPA Alex Pitz obtained copies of the facility records, interviewed Staff and Administrator. Investigation Branch (IB) Investigator Peter Zertuche also conducted a separate investigation regarding the same allegation. During the course of investigation, Investigator Zertuche interviewed nurse from the palliative care services agency, facility staff and resident and obtained medical record from the hospital.

Regarding the allegation that a resident had developed an unstageable pressure injury while in care, it was alleged that Resident #1 (R1) had an unstageable pressure sore when visited by a palliative care nurse on 08/04/21. (continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2022
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 3
Control Number 31-AS-20210809091844
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - LOUISE
FACILITY NUMBER: 197609742
VISIT DATE: 06/19/2022
NARRATIVE
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(continued from LIC 9099)

IB Investigator Vasquez interview with the nurse on 08/26/21 at about 2:30 PM, revealed that the nurse discovered R1 to have unstageable ulcers on left heel and coccyx area, the nurse added that R1 was not in hospice care nor there is a prior hospice care or home health services for R1. The nurse referred R1 to hospice care but the family member of R1 refused. Further interview with the nurse also revealed that the facility did not inform the palliative care agency nor the hospital to inform of R1’s pressure sore condition prior to or immediately after the nurse’s visit on 08/04/21. It was only on 08/09/21 that the facility brought R1 to the hospital without being treated at the facility. Investigator Zertuche’s interview with the administrator on 09/16/21 at around 12:00 PM, revealed that R1 was not brought to the hospital nor the facility contracted a hospice agency to care for R1’s wound because R1’s family member refused to do so. Moreover, Investigator Zertuche’s interview with two (2) care staff on 09/16/21 at 12:30 PM and 1:00 PM respectively, revealed that R1 was not being checked and/or changed diapers regularly, especially during nights. Investigator Zertuche’s medical record review on 08/26/21 at around 5:00 PM revealed that R1 had stage 3 pressure sore on coccyx and unstageable pressure sore on left heel.

Based on the information gathered during the course of the investigation, including interviews, and record review between 08/26/21 and 09/16/21, R1 developed pressure sore (Unstageable and Stage 3 pressure injuries) while in care. Therefore, the allegation is deemed substantiated at this time

Citation issued, appeal rights discussed and given.

Exit interview conducted and report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210809091844
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - LOUISE
FACILITY NUMBER: 197609742
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2022
Section Cited
CCR
87615(a)(1)
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Prohibited Health Condition (a) Persons who require health services for or have a health condition including, but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
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Administrator agreed to review regulations related to prohibited and restricted health conditions and send a written statement of understanding to CCL. Administrator and staff will complete a training on pressure injuries and proof of training will be sent to CCL on or before the POC date
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Based on interview and record review, the licensee did not ensure that R1 was not retained with a Stage 3 or 4 pressure injury and received proper treatment of the pressure injury, which posed an immediate health and safety 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3