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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222261
Report Date: 10/09/2024
Date Signed: 10/09/2024 03:57:03 PM


Document Has Been Signed on 10/09/2024 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:TRUDEZ HOME CAREFACILITY NUMBER:
191222261
ADMINISTRATOR:LOPEZ, WALDITRUDEZ P.FACILITY TYPE:
740
ADDRESS:15516 EL CAJON ST.TELEPHONE:
(818) 336-6537
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Mary Jane Rivera - AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Gary Tan, met with staff Flora and Domingo Calderon for a One (1) year required visit for this facility. Staff called the administrator Mary Jane Rivera who arrived at the facility twenty (20) minutes later. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 12:32 PM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors.. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is licensed to care for six (6) non-ambulatory resident and hospice waiver for one (1).
Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted:
Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 76°F. The smoke detectors were tested and observed to be operational. There is a fire extinguisher located in the kitchen and was observed to be full and last serviced on 04/29/24.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There is a shed being used as a used equipment storage observed to be locked during visit. (continued on LIC 9099-C)
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 191222261
VISIT DATE: 10/09/2024
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The garage is attached to the house but has no access from inside the house. It is also being used as laundry area, storage for frozen foods and old equipment. All the laundry detergents, cleaning solutions, toxins and other chemicals are observed to be locked in a cabinet and inaccessible to residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All sharps and knives were also observed to be locked in the kitchen cabinet below the sink. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was locked. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. Sink in the bathrooms were removed and under construction. The hot water temperature measured at 109.8°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication in the living room cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet.

Client records: Client records are reviewed. all residents' file appeared to be complete and updated. One (1) resident however is bedridden and the facility has no bedridden fire clearance.

Staff records: LPA conducted a complete file review of staff records. Two (2) out of two (2) staff records reviewed did not have health screening on file.

Disaster drill was last conducted on 09/30/24 . Required posting are observed to be complete and current and displayed properly at the facility.

Citation issued. Appeal rights discussed and given. Exit interview conducted and copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/09/2024 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: TRUDEZ HOME CARE
FACILITY NUMBER: 191222261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review the licensee did not comply with the section cited above in one (1) out of six (6) residents was bedridden per LIC 602, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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The administrator agreed to submit LIC 200 to get a bedridden fire clearance and/or remove the resident from the facility as soon as family agreed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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