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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602838
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:30:16 PM


Document Has Been Signed on 05/26/2022 03:30 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:
197602838
ADMINISTRATOR:LOPEZ,WALDITRUDEZFACILITY TYPE:
740
ADDRESS:23311 DALBEY DRIVETELEPHONE:
(661) 287-6191
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Virgil Lopez, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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At 10:30am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced annual inspection at the above facility. LPA met with the caregivers Jacla Basilica who granted access to home. This is a 5 bedroom, 2 bathroom, single story family residence that includes a living room, dining area, kitchen, laundry room and attached garage. LPA toured the entire facility with the caregiver and observed the following:

Infection control: Upon arrival LPA was not screened by the caregiver and was not asked any infection control questions. LPA had to prompt and guide staff through the screening process.

Food Inspection: At 10:50am LPA conducted a food inspection tour and found the following: The facility has enough sufficient supply of 2 days perishable foods and one week of non-perishable foods. LPA observed food cabinets to have pad locks. Food is locked at night to prevent a resident from having access. This is a personal rights violation. The kitchen knives were observed to be accessible to residents in care.

There is one carbon monoxide detector in the dining area. Smoke detectors were checked and are hardwired throughout the facility. Smoke detectors and carbon monoxide are observed to be operational.

Bedrooms: There are four bedrooms designated for residents' use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms are in poor repair at the front door, dining room area and in rooms #1, #3 and #4. The facility has Dementia residents in care and this poses a potential health and safety risk.

Bathrooms: At 11:10am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 131.4F. LPA observed

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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: 197602838
VISIT DATE: 05/26/2022
NARRATIVE
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appropriate grab bar and had non-skid mats. LPA did not observe appropriate hand washing signs posted in
each bathroom. Trash can in bathrooms need lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 72F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher in the kitchen area and was last serviced on 04/11/2022.

Surrounding Grounds: LPA toured the outside area of the facility. LPA observed various items stored in the backyard which need to be stored out of the way. LPA observed 3 hospital beds, garden tools and a garden hose that was used earlier, but not stored away. There are no bodies of water. Gate was unlocked and easily accessible to open. Facility has an appropriate shaded and seating area for residents outside.

The garage: Attached garage is used to store extra food, PPE supplies and chemicals. LPA observed the door kept unlocked and accessible to residents in care.

Medications: LPA observed residents medications are centrally stored and locked in the kitchen cabinet, however, staff room #5 has no door lock and at 11:00am LPA observed about 10 containers of random medications on a bed.
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Administrative: LPA collected Certificate of Liability Insurance and LIC.500 will be emailed to LPA.

Deficiencies issued per Title 22.

Appeal rights issued.

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: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/26/2022 03:30 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: 197602838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(7)(f)(1)(2)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) 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), the licensee did not comply with the section cited above. LPA observed the sharp knives, chemicals and medication to be accessible to residents in care. This is an immediate health and safety risk to residents care.
POC Due Date: 05/27/2022
Plan of Correction
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The administrator has agreed to lock all the sharps, chemicals and medication. Knives were immediately removed and locked. The Administrator agreed to purchase a lock for a garage door. Also a new cabinet will be purchased for the staff room to keep the medications locked and a training will be provided to all staff on the importance of maintaining medications chemicals and knives and sharp items inaccessible. The administrator shall submit staff sign in sheet with the topic and the training material along with pictures and or receipts.
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities


(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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. The licensee failed to follow the infection control protocol on screening procedures. Staff were not familiar with screening procedures, none of the thermometers were operating properly and no symptom screening questions have been asked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee agreed to train all staff on Mitigation Plan and Infection Control which includes screening. Staff sign-in sheet and training materials shall be e-mailed to LPA (Angela.Panushkina@dss.ca.gov)

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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/26/2022 03:30 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: 197602838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(3)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.


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 by keeping the food locked and inaccessible to residents in which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee agreed to remove all the locks from the cabinets and provide staff training on Personal Rights. Appropricate Care and Supervision needs to be provided. Staff sign-in sheet and copy of training materials will be emailed to the LPA
Type B
Section Cited
CCR
87303(a)

87303 Maintenance and Operation
(a) 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. Autditorial device in an entry door, rooms #1, #3 and #4 were in poor repair and non operational, which poses a potential health, safety risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee agreed to buy new alarm system for the doors and the copy of the receipt and proof of photos or receipt will be emialed to LPA

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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/26/2022 03:30 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: 197602838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
887303(e)(2)
87303(e)(2) Maintenance and Operation
Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation hot water was measured at 131.4°F. Licensee did not comply with the section cited above in ensuring that the hot water tepmerature was within range which poses an immediate health and safety risk to the residents in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator agreed to adjust the hot water temp and will submit a daily water temp log for 1 week (AM/PM) to ensure compliance and will submit a copy of the log to CCL on or before 06/03/22.
Type A
Section Cited
CCR
87202(a)(2)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and staff interviews, the licensee did not comply with the section cited above by retaining 1 bedridden residents without a berdidden fire clearence, which poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date: 05/27/2022
Plan of Correction
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icensee / Administrator will submit LIC200 and Facility Sketch. Facility sketch will need to specify rooms for bedridden residents. This is a zero tollarance violation, therfore, a civil penalty in the amount of $500.00 has been issued. Civil penatlty in the amounto $100.00 per day will occure until POC is received.

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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5