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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601592
Report Date: 12/21/2021
Date Signed: 12/21/2021 07:00:45 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/04/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210604142033
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: 5DATE:
12/21/2021
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Consuelo Connie CiprianoTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Allegation: Resident 1 (R1) developed a prohibited health condition due to improper care
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. This investigation was conducted by Edward Hector, Investigator with Community Care Licensing Division’s Investigations Branch.

Regarding the allegation it was reported that resident 1 (R1) had a significant decline in condition from 12/9/2020 which was not reported to the resident’s physician. In addition, it was reported that on 6/2/2021 during a semi-Annual medical visit conducted at the facility R1 was found to have an unstageable pressure injury which R1’s physician did not have knowledge of.

During the course of the investigation, From November 5, 2021 through November 12,2021 Investigator Hector conducted interview with various individuals including the licensee, facility staff, resident 2 (R2), and R1’s family/responsible party. On 6/7/2021 during the initial 10 day complaint visit LPA Avetisyan conducted interviews with the administrator and staff 1 (S1). On 7/16/2021 Investigator Hector received and reviewed R1’s medical records from Kaiser Permanente.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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 4
Control Number 31-AS-20210604142033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197601592
VISIT DATE: 12/21/2021
NARRATIVE
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Information obtained from the interviews conducted and records reviewed revealed the following: Staff 1 (S1) observed the development of the pressure injury approximately the first week of May 2021 and provided treatment to the pressure injury. S1 expressed observing the area of the pressure injury progress to the color black. S1 reported that she and R1’s family/responsible party would provide wound care to R1. According to S1, R1’s family/responsible party contacted the doctor, which resulted in a visit by a medical staff.

When interviewed on 11/5/2021 the licensee Waldi Lopez informed investigator Hector that R1 was on Palliative care with Kaiser before reported as having a pressure injury. Licensee also stated that they contacted Kaiser reported the residents decline and need for hospice care. Licensee could not provide a timeline of when these actions were taken. Licensee also indicated that R1’s responsible party would provide wound care to the resident with staff.

When interviewed on 11/12/2021 R1’s family/responsible party disclosed being aware that S1 was treating R1’s wound, however she did not witness S1 or any facility staff provide wound care and denied assisting S1 or other facility staff to provide wound care. Additionally, R1’s responsible party indicated that she had no knowledge of the extent of the injury until Kaiser began treatment.

On 12/9/2021 LPA Avetisyan conducted interview with the Kaiser Nurse Practitioner (NP) who visited R1. During the phone call the NP conducted review of R1’s medical records. While reviewing the records NP confirmed that R1 did not have an order or was receiving Palliative care prior to the 6/2/2021 home visit. R1’s records did not document communication from any individual regarding the change in R1’s condition or the pressure injury. The 6/2/2021 visit was a Semi-Annual visit and was not conducted due to a requested follow up.

Information obtained during the course of the investigation revealed that the licensee/ administrator /staff neglected to address the change in R1’s condition by failing to notify R1’s physician when the pressure injury developed. Additionally, Staff 1 who is not a skilled medical professional provided improper care to the pressure injury resulting in the pressure injury worsening and being documented as Unstageable on 6/2/2021 therefore the allegation is Substantiated at this time. Exit interview conducted, with staff and copy of report, citations, civil penalties and appeal rights emailed to info@trudezhomecare.com

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210604142033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197601592
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2022
Section Cited
CCR
87615(a)(1)
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Persons who require health services for or have a health condition including, but not
limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3, 4, unstageable pressure injuries. This Requirement was not met as evidenced by:
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Licensee/Administrator and all staff will attend at least 8 hours vendorized training regarding all sections cited on this report as well as allowable, restricted health conditions, hospice care, exception request.
Verification of scheduled training with the trainers credentials will need to be submitted to LPA by 12/23/2021 and
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Based on information obtained during the investigation, the licensee/ administrator/staff did not comply with the cited section by retaining R1 at the facility who developed a prohibited health condition due to improper wound care which posed an immediate health and safety and personal rights risk to R1
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verification of completed training will need to be submitted to LPA by 1/7/2022

A civil penalty in the amount of $500 has been issued due the neglect/lack of timely medical care which resulted in R1 developing a prohibited health condition.
Type A
12/23/2021
Section Cited
CCR
87611(c)
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87611 (c) In addition to section 87411(d), facility staff shall have knowledge and the ability to recognize and respond to problems and shall contact the physician, appropriately skilled professional, and/or vendor as necessary. This Requirement was not met as evidenced by:
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Licensee/Administrator and all staff will attend at least 8 hours vendorized training regarding all sections cited on this report as well as allowable, restricted health conditions, hospice care, exception request.
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Based on information obtained during the investigation, the licensee/administrator/staff did not comply with the cited section by not having the knowledge and the ability to respond properly by contacting R1’s physician when R1 developed the pressure injury which posed an immediate health and safety and personal rights risk to R1
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Verification of scheduled training with the trainers credentials will need to be submitted to LPA by 12/23/2021 and verification of completed training will need to be submitted to LPA by 1/7/2022
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20210604142033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197601592
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
87631(a)(3)(A)
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the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:(3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. A)The resident shall receive care for the pressure injury from a physician or an
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immediate health and safety and personal rights risk to R1.

Licensee/Administrator and all staff will attend at least 8 hours vendorized training regarding all sections cited on this report as well as allowable, restricted health conditions, hospice care, exception request.
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appropriately skilled professional. This Requirement was not met as evidenced by: Based on information obtained during the investigation the licensee/administrator/staff did not comply with the cited section by not having R1’s pressure injury diagnosed and cared for by a physician or an appropriately skilled medical professional which posed an
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Verification of scheduled training with the trainers credentials will need to be submitted to LPA by 12/23/2021 and verification of completed training will need to be submitted to LPA by 1/7/2022
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4