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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602838
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:57:28 PM


Document Has Been Signed on 06/22/2023 04:57 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: 2DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anita Collado TIME COMPLETED:
04:54 PM
NARRATIVE
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At 10:30am Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced annual inspection at the above facility. LPA met with the caregivers Anita Collado and explained the reason for the visit. The administrator, Waldi Lopez, stated that she had an emergency and designated Anita Collado to sign and accept this report. This is a five (05) bedroom, two (02) 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:

Food Inspection: At 10:45am 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. 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.

Bathrooms: At 11:20am 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 106.8F. LPA observed appropriate grab bar and had non-skid mats.



Common Areas: The facility maintains a comfortable temperature at 76F. 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 04/18/2023.

(CONT. LIC809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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: 06/22/2023
NARRATIVE
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Surrounding Grounds: LPA toured the outside area of the facility. 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.

Medications: LPA observed residents’ medications are centrally stored and locked in the kitchen cabinet.

Deficiencies issued per Title 22.
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Exit interview conducted and copy of this report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/22/2023 04:57 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: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as the facility did not make sharps and knives inaccessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87705(f)(1); The written letter must be sent to the LPA by the POC due date. Also, Licensee shall have broken lock for sharps and knives repaired and send LPA a picture.
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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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