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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609742
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:59:51 AM

Document Has Been Signed on 06/21/2022 10:59 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: 6DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Annabelle Pascua TIME COMPLETED:
11:10 AM
NARRATIVE
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On 06/21/22 at 9:40 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with Administrator Designee Annabelle Pascua. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 9:50 a.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet in the kitchen area. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 10:05 a.m. and appear to be functional. Fire extinguisher has a purchase date of 04/11/2022. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 81F. Resident Rooms: Facility has seven (7) bedrooms which of six (6) are designated for resident use. Facility has two live-in staff. All seven (7) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for resident’s use. LPA observed all bathrooms to be cleaned. At 9:54 a.m LPA toured the bathroom next to bedroom number three (3). LPA observed a can of cleaning supply under the bathroom sink. LPA asked staff to immediately remove the cleaning supply and store it in the locked cabinet located under the kitchen sink. The hot water was tested and measured 106.5 F, which is in regulation. All trash cans located in the bathrooms had tight fitting lids. (Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/21/2022
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Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a shack located outside that is used for additional storage and laundry chemicals storage. The laundry area is located outside. There is a body of water that has a wooden cover and a gate around the pool making it inaccessible to residents.

The following deficiency were observed and cited per Title 22 see attached LIC809D.

Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2022 10:59 AM - It Cannot Be Edited


Created By: Joscelyn Martinez On 06/21/2022 at 10:28 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: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

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Care of Persons with Dementia 87705 (f) (2)
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by
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Based on observation, the licensee did not comply with the section cited above in ensuring cleaning supplies are inaccessible to residents which poses immediate health, safety or personal rights risk to persons 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
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