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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601592
Report Date: 02/15/2022
Date Signed: 02/15/2022 06:24:06 PM

Document Has Been Signed on 02/15/2022 06:24 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:
197601592
ADMINISTRATOR:LOPEZ, VIRGILIOFACILITY TYPE:
740
ADDRESS:23844 VIA JACARATELEPHONE:
(661) 259-7019
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 3DATE:
02/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Consuelo Cipriano, StaffTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina, conducted a case management, in conjunction to a complaint investigation, with control number 31-AS-20220210104450. During the investigation, it was revealed that two deaths occurred at the facility on 09/07/21 and 01/28/22, and the facility did not submit any Death Reports to Licensing agency. LPA spoke with the Administrator over the phone and the Administrator could not provide an explanation as to why the Death Reports were not sent to Licensing agency. Administrator asked to contact the facility Licensee, Walditrudez Lopez, for more information. Licensee was contacted and could not provide any explanations to LPA regarding the Death Reports not being submitted. LPA expressed the concern of not reporting incidents to Licensing agency and requested both reports to be submitted to Community Care Licensing Department (CCLD) promptly. This is a potential health and safety risk to residents in care.

Citation issued, and copy of this report was emailed to the Administrator, Virgilio Lopez
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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 2
Document Has Been Signed on 02/15/2022 06:24 PM - It Cannot Be Edited


Created By: Angela Panushkina On 02/15/2022 at 03:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2022
Section Cited
CCR
80061(b)(1)(D)

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Reporting Requirements. (b) during the operation of the facility...(1) below, a report shall be made to the licensing agency within...seven days following the occurrence of such event... (D) Any injury to any client..

This requirement was not met evidenced by:
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Administrator ensured LPA that incident/death reports will be submitted acording to Licensing regulations. Death reports for both residents shall be submitted to LPA by POC date.
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Based on the interviews and record review, the Administrator did not comply with the section cited above by not reporting an incident/death of two residents to Licensing agency, which poses a potential health and safety risk to clients 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 Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2