<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609742
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:51:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
11/23/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20211123104538
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:
10/27/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Anabel Pascua - Co administratorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained an unstageable pressure injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Co-Administrator, Anabel Pascua and explained the reason for today’s visit.

On 11/23/2021, the Department received a complaint alleging that Resident (R1) had sustained an unstageable pressure injury while in care. The complaint was referred to the Investigation Bureau (IB) on 11/23/21 but was rescinded due to involvement of Home Health Services for R1.

The Department initiated the complaint investigation on 11/24/2021 at 9:43 AM. LPA conducted physical plant tour at 9:45 AM, obtained copies of the facility records relevant to the investigation at 10:00 AM and interviewed the Administrator and Home Health Nurse at 11:00 AM.

(continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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 2
Control Number 31-AS-20211123104538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRACY'S BOARDING CARE - LOUISE
FACILITY NUMBER: 197609742
VISIT DATE: 10/27/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(continued from LIC 9099)

It was alleged that Resident #1 (R1) was discharged from the hospital in September 2021 with Stage two pressure wounds and taken to the board and care. R1 was returned to the same hospital and was admitted on 11/17/21 with unstageable decubitus ulcer of the buttock.

LPA’s record review on 04/10/22 of facility, hospital and home health records revealed that R1 was admitted to the facility on 07/31/21 with an initial diagnosis of colon cancer with the recommendation for Home Health for wound assessment, Ostomy Care, Caregiver Teaching and Physical Therapy. R1 was admitted by a home Health agency on 08/02/21 for various health issues including but not limited to a Stage 2 pressure ulcer. On 08/02/21, R1 was assessed by home health wound nurse to have a Stage 2 pressure sore on left buttock. R1 was put on three (3) Home Health nurse visits for the first week and two times a week for the next eight (8) weeks. Further review also revealed that R1 was on home Health services from 08/02/21 up to R1’s last hospitalization on 11/17/21 wherein R1 did not return to the facility and was placed in a Skilled Nursing Facility. Further review also confirmed that caregivers of the facility were educated on how to care for R1’s wound and in general by the Home Health Nurse (HHN). LPA’s interview with HHN on 11/24/21 at around 11:30 AM confirmed that the HHN was at the facility caring for R1 and was the one who called 911 due to R1’s behavior on 11/17/21 when R1 was hospitalized. Further, HHN confirmed training the staff on how to provide care for R1. LPA’s interview with staff on 04/12/22 at 10:52 AM revealed that the staff change R1’s diaper on a regular basis and turned R1 every two (2) hours as instructed.

Based on the information gathered during the course of the investigation, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time.

Exit interview conducted and report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2