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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609742
Report Date: 08/06/2025
Date Signed: 08/06/2025 12:52:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
07/31/2025 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250731143056
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: 4DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Thresiamma Mathew, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Facility staff refused to readmit resident
Staff does not ensure resident is dispensed medications as prescribed
INVESTIGATION FINDINGS:
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On 08/06/25, at 9:14am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by George Siapno, Caregiver. The licensee Thresiamma Mathew was called and arrived about fifteen (15) minutes after. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint.

On 08/06/25, at 9:50am, LPA Saucedo asked for the census, staff, and resident rosters. At 10:10am, LPA Saucedo conducted a physical tour, interviewed staff and obtained the following documents-Resident Appraisal, Appraisal/Needs and Services Plan, Admission Agreement and Pre-placement.

LIC 9099C-continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
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-20250731143056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - LOUISE
FACILITY NUMBER: 197609742
VISIT DATE: 08/06/2025
NARRATIVE
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Regarding the allegation: Facility staff refused to readmit resident. It is being alleged that the administrator of the care home is refusing to take the resident back from the hospital upon discharge. LPA interviewed three (3) staff that confirmed that due to resident #1 (R1)’s behavior, R1 is not being allowed to return back to the above facility. LPA reviewed the facilities admission agreement regarding R1, R1’s pre-placement and resident appraisal. There was no reassessment/updated resident appraisal and/or reappraisals conducted for R1 showing the process of eviction. There was no eviction notice given to the resident, resident’s family and Community Care Licensing Department about not accepting/readmitting R1 back to the facility from the hospital. The pre-placement stated R1 had behavioral problems and agitation at times. The resident appraisal and Appraisal/Needs and Services Plan showed that R1 would have psychosis behavior. Therefore, based on the LPA's record reviews and staff interviews conducted, the allegation is SUBSTANTIATED at this time.

Regarding the allegation: Staff does not ensure resident is dispensed medications as prescribed. It is being alleged that the resident has not been receiving their psychotropic medication(s) at the facility. LPA interviewed three (3) staff that confirmed resident #1 (R1) was provided medication. LPA asked if R1 was being provided their psychotropic medication and staff failed to prove that R1 was being provided psychotropic medication. LPA received pictures of the medication packets from a witness that showed between 07/26/25 to 07/30/25 the medication were still inside of the packets. The medications that were not dispensed/given to the resident were-Divalproex (bipolar disorder) and Quetiapine Fumarate (psychosis). The staff sent R1 to the hospital on 07/30/25 for hitting staff and aggressive behavior. Furthermore, the medication Atorvastatin (to lower cholesterol and triglycerides) was not given to R1. LPA spoke to one (1) of the hospital staff that confirmed R1 was doing well after being provided their psychotropic medication. Therefore, based on the LPA's record reviews/medication review and staff interviews conducted, the allegation is SUBSTANTIATED at this time.

An exit interview was conducted, citation(s) were issued, appeal rights were provided, and a copy of this report was given to the resident care director.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250731143056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - LOUISE
FACILITY NUMBER: 197609742
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2025
Section Cited
CCR
87224(a)
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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement is not met by:
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Licensee/Administrator will ensure to send community care licensing department a proper thirty (30) day notice regarding R1

The POC due date: 08/07/25
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Based on the LPA's Interviews the licensee/administrator failed to ensure that resident #1 (R1) was not given the proper 30 (thirty) day notice for eviction. R1 was not allowed back to the facility after hospitalization discharge. This posed an immediate health and safety risk to residents in care.
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Type A
08/07/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met by:
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Licensee/Administrator will ensure to train all staff on medication management.

The POC due date: 08/07/25
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Based on the LPA's Interviews the licensee/administrator failed to ensure that resident #1 (R1) was being provided all their medication. This 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: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3