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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800845
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:25:19 PM

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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANGELS ON TRACYFACILITY NUMBER:
565800845
ADMINISTRATOR:JO ANN TRUPIANOFACILITY TYPE:
740
ADDRESS:2409 TRACY AVE.TELEPHONE:
(805) 583-3293
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 3DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jo Ann TrupianoTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA) Martha Guzman Chavez conducted an unannounced visit to conduct a Required Annual inspection with a focus on Infection Control. LPA was greeted at the door by Staff member Paul. At 11:40am Administrator Jo Ann Trupiano arrived at the facility and was explained the reason for the visit.

At 11:33am, LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens and a night stand. LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet in the kitchen next to the stove. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Emergency food supply was stored in the garage. Medications were stored in a locked cabinet in the living room. LPA observed First-Aid kit and it was complete. Fire extinguisher was observed by LPA to be last serviced/charged on 4/27/2021. LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. Water temperature was checked and in compliance at 107.8 degrees Fahrenheit. LPA observed the backyard to have a covered outdoor area with a table and chairs. There is a gate on the side of the house that has a single latch and always remains unlocked.

LPA did not observe a sufficient amount of the following: 30 day supply of masks. Let Administrator know they can contact their LPA to schedule an appointment to pick up a 30-day supply of PPE at the office.

Continued on LIC 809c

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANGELS ON TRACY
FACILITY NUMBER: 565800845
VISIT DATE: 07/12/2021
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Continued from LIC 809

LPA did make the recommendation to the administrator to post CDSS PINs in easily accessible location for all residents.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC809 (FAS) - (06/04)
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