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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601592
Report Date: 12/21/2022
Date Signed: 12/21/2022 08:53:27 PM


Document Has Been Signed on 12/21/2022 08:53 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: 2DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Consuello Cipriano, Staff TIME COMPLETED:
03:15 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 Consuello Cipriano (staff), who granted access to the facility. The Administrator was contacted over the phone and LPA explained the reason for the visit.

At 10:30am, 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 locked in a kitchen drawer and inaccessible to residents. The fire extinguisher was last serviced on 04/11/2022.

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



Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. LPA observed full rails placed on bed. Facility has an extra room for the live-in staff members


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. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 74°F. The living room and dining area
appeared clean and were properly furnished and the fireplace is adequately screened. No obstructions and or tripping hazards throughout the facility. During the walk through, LPA opened the closet door, by the main Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592
VISIT DATE: 12/21/2022
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entrance, and observed a container with medications prescribed to Staff #2 (S2). LPA requested to remove medications from the closet and place it in a locked cabinet, immediately.

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

Outside areas: At approximately, 11:10am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA also observed various items stored in the backyard which need to be stored out of the way. LPA observed old/broken washer and a dryer, broken night stand, two mattresses and a hospital bed. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water. Gate was unlocked and easily accessible to open.


Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:30am they were tested and observed to be operational.


Additional Visit Information:
  • Upon arrival to the facility LPA was told the facility currently has two (2) residents of which one (1) out of two (2) residents comes to this facility from 7:00am - 4:00pm for five (5) to seven (7) days a week. LPA attempted to contact Mr. Lopez to inform that the facility cannot be used as an Adult Day Care and if this individual is going to be at the facility they have to have a file for him/her. LPA also observed staff feeding the individual.
From 11:30am to 12:00pm LPA conducted review of resident files and observed the following:
  • R1's facility file had an Admission Agreement completed, only, and rest of the documents were left blank. In addition, the Physician Report was missing and LPA was informed that R1 moved to this facility
on 12/18/22 and the facility still haven't received the completed document from R1's physician.
  • LPA did not observe any orders on file for a full bed rails for R1.

Deficiencies issued per Title 22. Exit interview conducted, appeal rights discussed and copy of this report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 12/21/2022 08:53 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: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above by not ensuring medications for S2 are kept inaccessible to resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2022
Plan of Correction
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Licensee/Administrator will need have an in-service training with all staff members regarding this deficiency and a proof of training shall be submitted to LPA bye POC date.
Type A
Section Cited
CCR
87608(a)(5)(D)
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations mad, the licensee did not comply with the section cited above by utilizing full bedrails for R1 who is on hospice. However, licensee does not have hospice care plan which indicates the need for the rails which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 12/22/2022
Plan of Correction
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Licensee/Administrator will request a current hospice care plan for a resident which indicates the need for the full rails. Copy of the Hospice care plans will need to be submitted by 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/21/2022 08:53 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: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 (a) Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 by not maintaining complete facility files for residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2022
Plan of Correction
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Licensee/Administrator will complete files for all residents. Once completed licensee/administrator will submit a signed, dated self certification that all resident files have been, reviewed, updated and complete as required by the cited regulation.
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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4