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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600297
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:30:02 PM


Document Has Been Signed on 12/28/2022 02:30 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:TRUDEZ HOME CAREFACILITY NUMBER:
197600297
ADMINISTRATOR:LOPEZ, VIRGILIOFACILITY TYPE:
740
ADDRESS:25821 OLIVAS PARK ROADTELEPHONE:
(661) 259-1827
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:5CENSUS: 4DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eileen Calderon, StaffTIME COMPLETED:
01:15 PM
NARRATIVE
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At 10:15am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by Eileen Calderon (staff), who granted access to the facility. The Administrator was contacted over the phone and LPA explained the reason for the visit.

At 10:25am, LPA conducted a tour of the facility with staff and the following was observed:

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be unlocked in a kitchen drawer and accessible to residents. The facility has Dementia residents in care and this poses an immediate health and safety risk.

Medications: At approximately, 10:35am LPA observed medications are centrally stored and locked in a kitchen cabinet and inaccessible to residents in care.



Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. Facility has an extra room for live-in staff members and LPA observed 2 medication bottles in the drawer that were not locked and accessible to Dementia residents in care.


Bathrooms: At 11:00am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and non-skid mat. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area
Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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 3


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: TRUDEZ HOME CARE
FACILITY NUMBER: 197600297
VISIT DATE: 12/28/2022
NARRATIVE
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appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:10am they were tested and observed to be operational.


Outside areas: At approximately, 11:20am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Laundry area is located in an attached garage and kept locked. Extra PPE supplies and food storage was also observed.

Deficiencies issued per Title 22. Exit interview conducted and copy of this report emailed to the Administrator.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/28/2022 02:30 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197600297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents...(1) Knives, matches, firearms...(2) Over-the-counter medication...

This requirement is not met as evidenced by:
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Administrator will provide a training to all staff on the importance of maintaining knives and medications inaccessible to residents in care. The administrator shall submit staff sign in sheet with the topic and the training material to LPA by POC date.
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Based on observation, the licensee did not comply with the section cited above by providing care and supervision to persons with dementia and having knives and medications accessible to residents in care, which poses an immediate health and safety or pesonal 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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
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