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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222261
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:54:03 PM


Document Has Been Signed on 10/26/2023 03:54 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: 5DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Flora Calderon - StaffTIME COMPLETED:
04:00 PM
NARRATIVE
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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.

A tour of the physical plant was conducted at 1:40 PM and the following was noted:

There is only one entrance being utilized at the facility, there are required poster posted at the main door. 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 outside the doors. 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 five (5) 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 04/18/23. 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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: 10/26/2023
NARRATIVE
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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 118.9°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, Three (3) out of five (5) had a diagnosis of dementia and no updated medical assessment on file.

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 09/14/23 . 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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/26/2023 03:54 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: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in wherein one (1) bedroom is under construction and some parts of the walls are exposed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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The administrator agreed to hasten the construction of the parts of the house and submit proof of repair to CCL on or before the POC date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as two (2) of the (3) bathroom sink are not operational during visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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TThe administrator agreed to hasten the construction of the parts of the house and submit proof of repair to CCL on or before the POC date.
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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/26/2023 03:54 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: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff record reviewed had no health screening on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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The administrator agreed to obtain health screening for the two (2) staff and submit a copy to CCL on or before the POC date.
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on ecord review, the licensee did not comply with the section cited above in 3 out of 3 dementia residents did not have updated medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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The administrator agreed to obtain current medical assessment for three (3) dementia residents and submit a copy to CCL on or before the POC date.
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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4