Tracy's Boarding Care - Lassen

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Allegation investigated: Uncleared staff caring and supervising residents

Licensing Program Analyst (LPA) Tuesday Cabiness and Licensing Program Manager (LPM) Nichelle Gillyard conducted the initial visit to investigate the allegation mentioned above. LPA met with Administrator Tracy Mathew and informed her the reason of the visit. The following information was provided during the investigation: Allegation #1: Uncleared staff are caring for and supervising residents. To investigate the allegation, during today’s visit, from 9:00 a.m. to 2:00 p.m., (LPA) and (LPM) conducted a physical plant inspection, interviewed two (2) staff and four (3) residents, and obtained and reviewed facility documentation. According to the complaint, several staff members working at the facility were reportedly not associated with the facility and had not obtained criminal record clearance. During the visit, LPA requested and reviewed the facility’s staff schedule and resident roster. The staff schedule did not identify the names of staff working each shift or the number of hours worked, which limited LPA’s ability to verify staffing information. (Cont'd LIC9099C) Substantiated Through interviews, LPA learned that on a specific date, an individual was scheduled to work as a relief staff member for approximately four (4) hours. Further information obtained during the investigation confirmed that the individual was not associated with the facility and did not have a criminal record clearance at the time the individual provided care and supervision to residents. Based on interviews and review of facility records, LPA determined that an individual without an association to the facility and without a criminal record clearance provided care and supervision to residents. Therefore, the allegation that uncleared staff are caring for and supervising residents is determined to be Substantiated. Citation issued, civil penalty, appeal rights, exit interview, and copy of report provided to Administrator. In addition, LPA observed two (2) additional refrigerators stocked with food. Interviews with residents indicated that the facility provides adequate and satisfactory meals. Residents did not report that they were routinely served only canned soup and spaghetti or that they were not provided with sufficient food options. Although the allegation stated that the facility does not follow its food menu, Title 22 regulations do not require a facility to follow a specific menu. Based on LPA’s observations, resident and staff interviews, review of facility documentation, and applicable regulations, there is insufficient evidence to establish the allegation that staff do not follow the facility’s food menu is determined to be Unsubstantiated. Allegation #2: Staff are not properly storing food. To investigate the allegation, during today’s visit, from 9:00 a.m. to 2:00 p.m., (LPA) and (LPM) conducted a physical plant inspection, interviewed two (2) staff and four (4) residents, and obtained and reviewed facility documentation. It was alleged that staff were not properly storing food at the facility. During the inspection, LPA observed the main refrigerator to be clean, organized, and adequately stocked. Food items were properly stored, wrapped, and labeled. LPA also observed two (2) additional refrigerators stocked with food items. The food items in the additional refrigerators were also observed to be properly stored and labeled. Based on LPA’s direct observations during the physical plant inspection, as well as interviews, there were no concerns regarding improper food storage identified. Therefore, there is insufficient evidence to establish that staff are not properly storing good, therefore is determined to be Unsubstantiated. Allegation #3: Staff do not provide a comfortable temperature for residents. To investigate the allegation, during today’s visit, from 9:00 a.m. to 2:00 p.m., the Licensing Program Analyst (LPA) and Licensing Program Manager (LPM) conducted a physical plant inspection, interviewed two (2) staff and four (4) residents, and obtained and reviewed facility documentation. It was alleged that Resident #1’s (R1’s) room was hot and that staff unplugged the portable air conditioner in R1’s room. During the physical plant inspection, LPA measured the temperature throughout the facility, including the common areas, R1’s room, and other residents’ rooms. The temperatures observed were comfortable and within the range required by Title 22 regulations. (Cont'd LIC9099C) LPA interviewed R1, who reported that she did not like the portable air conditioner in her room and did not want it turned on. The Administrator and staff interviewed denied unplugging the air conditioner or otherwise interfering with its use. Based on LPA’s direct observations, temperature measurements, interviews with R1 and facility staff, there is insufficient evidence to establish that staff failed to maintain a comfortable temperature for residents. Therefore, the allegation is determined to be Unsubstantiated. Exit interview and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 1, 2026 · control 31-AS-20260825161602

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.17(D) · Plan of correction due date: Sep 2, 2026

Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances;...(D) It is the intent of the Legislature in enacting this section to require the fingerprints of those individuals whose contact with clients of residential care facilities for the elderly may pose a risk to the clients’ health and safety. An individual shall be required to obtain either a criminal record clearance or a criminal record exemption...This requirement was not met, evidenced by, during the investigation, it was revealed a staff not cleared to work, providing care to clients in care. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Administrator has AGREED to make sure all new hires have criminal record clearance before working and entering the facility. And LPA obtained a current staff schedule for those working currently working at the facility. POC is cleared during the visit.

Type of visit: Required - 1 Year

On 05/19/25 at 11:07AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Anabelle Pascua and disclosed the purpose of the visit. Thresiamma Mathew the licensee arrived shortly after. LPA asked for the census, resident, and staff files. A physical tour was conducted at 11:25 AM and observed the following: The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. There is one (1) refrigerator and one (1) pantry area with extra food. The kitchen area was clean at the time of the tour. Under the kitchen sink the knives and chemicals are kept locked and inaccessible to the residents. On your right-hand side of the kitchen the fire extinguisher is located fully charged with an expiration date of April 2026. Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does has a signal system. The facility does not have a pool or any bodies of water. The outside/backyard can be accessed from the dining/living room area and hallway area. There is two (2) sheds in the backyard with resident property and extra wheelchairs and bedding. The washer and dryer are located outside in the backyard. By the washer and dryer there are two (2) doors where there is access to one (1) storage area and one (1) office. LIC 809C-continued Bedrooms: There are seven (7) bedrooms and four (4) bathrooms. Two (2) of the seven (7) bedrooms have private bathrooms. One (1) of the seven (7) bedrooms is used as a staff room. There are six (6) resident's rooms, one (1) is currently vacant. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 117-118-degree Fahrenheit. There is extra linen in the hallway. The medication is locked and inaccessible to the residents in the hallway on the top shelf. The first aid is kept under the medication shelf also in the hallway. The dining/living room area has enough seating for the residents and the staff. The dining room area has a television, internet access and a telephone. The house temperature is at 72-degree Fahrenheit. There are several smoke detectors/carbon monoxides (dual) in the dining/living area that are operable. Administrative: At the entrance of the facility on your right-hand side there is door with extra PPE items, administrator License certificate, Yes, Emergency/Disaster Plan, Ombudsman, Home Rules and Rights of Individuals, Theft and Loss Policy, Emergency Contacts and the surety bond is updated and expires 09/2025. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: POC

On 03/04/25, at 9:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, Plan Of Correction (POC) and was greeted by Administrator, Anabelle Pascua. The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 10/16/2024. At 10:15 AM LPA toured the facility and requested the following: LPA interviewed staff to determine if there was an updated staff roster showing that a staff works during the night shift which has not been sent to the LPA. There is five (5) dementia residents that reside at the above facility which requires night supervision. LPA has not received any Unusual Incident/Injury reports regarding any of the residents being sent to the hospital and/or injuries. From the previous report on 10/16/24, there was one resident, resident #1 (R1) had received two (2) seizures, 911 was called and transported to the hospital. On one (1) of the seizure incidents, R1 had fallen from their wheelchair and none of these incidents were reported and/or sent to CCLD-Community Care Licensing Department. LPA cleared the POC that required postural support. There is no residents requiring postural support at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 cited and noted on LIC 809-D. Two (2) citations will be issued on 809-D for non-reporting to CCLD and for no night supervision which is required for dementia residents. An exit interview was conducted, citation(s) were issued, appeals rights and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Mar 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Mar 12, 2025

87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure resident reports to be submitted to CCLD from the above facility involving multiple incidents which poses a potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: An Unusual Report is to be sent to Community Care Licensing Department within seven (7) days regarding a death report and/or resident injuries/hospitalizations while in care. POC Due Date: 03/12/25

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(e)(5) · Plan of correction due date: Mar 12, 2025

87705 Care of Persons with Dementia (e) Licensees..5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating.. Personal Rights of Residents in All Facilities.. Additional Personal Rights of Residents in Privately Operated Facilities.This requirement is not met as evidenced by: Based on the observation, interviews and record reviews, the licensee did not ensure one out of three staff at the facility to be on duty at night and supervise the care of the residents of dementia have which poses a potential Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: The licensee/admnistrator will send the LPA an updated personnel report showing the caregivers schedule showing there is a night person on duty seven (7) days out of the week to care for residents with dementia. POC Due Date: 03/12/25

Type of visit: Case Management - Deficiencies

On 10/16/24, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced case management visit and was greeted by Administrator, Anabelle Pascua. LPA was advised that incidents reports were not being sent to Community Care Licensing Department-(CCLD). While conducting staff interviews and record review, LPA discovered that resident #1 (R1) had received two (2) seizures, 911 was called and transported to the hospital. On one (1) of the seizure incidents, R1 had fallen from their wheelchair and none of these incidents were reported and/or sent to CCLD. In addition, R1 has a postural support that does not have a prescription and/or authorized by a doctor. During LPA’s physical tour, LPA observed roaches crawling on the wall of the above facility. Previously LPA has asked for the staff roster showing that a staff works during the night shift and it has not been sent to the LPA. Furthermore, there is dementia residents at the above facility that need night supervision. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 cited and noted on LIC 809D. Exit interview conducted, four (4) citation(s) given, appeal rights and copy of report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Oct 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Oct 16, 2024

87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure resident reports to be submitted to CCLD from the above facility involving multiple incidents which poses a potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: An Unusual Report is to be sent to Community Care Licensing Department within seven (7) days regarding a death report and/or resident injuries/hospitalizations while in care. POC 10/30/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Oct 16, 2024

A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on observation the licensee failed to ensure that Resident has a written order for postural support placed in Residents file. This poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: The Licensee/Administrator will contact resident physicians to obtained required medical documentation for postural supports. POC due date:10/30/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 16, 2024

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: Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have a clean and sanitary facility including rooms, common areas clean of roaches thus ensuring the facility was clean, which poses a potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: The administrator/Licensee must at all times keep a facility free of roaches. The administrator/licensee is to show proof of pest control service/documentation and send to LPA by POC 10/30/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR8705(c)(4)(A) · Plan of correction due date: Oct 16, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care...safety and health care needs… (A) In addition to... specified in Section 87415, Night Supervision, a facility with fewer than 16...at least one night staff person...This requirement is not met as evidenced by: Based on the observation, interviews and record reviews, the licensee did not ensure one out of three staff at the facility to be on duty at night and supervise the care of the residents of dementia have which poses a potential Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: The licensee/admnistrator will send the LPA an updated personnel report showing the caregivers schedule showing there is a night person on duty seven (7) days out of the week to care for residents with dementia. LPA by POC 10/30/2024

Allegation investigated: Staff does not ensure bathroom supplies are made available for residents and residents guests

On 10/08/24, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Caregiver Masoledad Calantog. LPA disclosed the purpose of the visit and was able to meet with the administrator about thirty (30) minutes after arrival. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:45am, LPA toured the physical plant. 9099-continued Unsubstantiated This is an amended copy of the report previously issued on 10/08/2024. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same. Regarding the allegation: Staff does not ensure residents are allowed to have visitors. It is being alleged that a visitor was asked to not visit the facility anymore. LPA interviewed three (3) staff out of four (4) staff that confirmed that the visitors do not stay long when the residents receive visits. Furthermore, Three (3) out of the four (4) staff confirmed that the visitors they do get at the above facility do not interfere with their work duties and/or tell them what to do. Three (3) staff confirmed that the administrator told them not to let certain visitors enter the above facility. LPA was able to observe that two (2) visitors arrived and visited approximately an hour and left. LPA was only able to interview one (1) out of (5) five residents. One (1) resident confirmed that they are doing well and have no issues at the above facility. Therefore, based on the LPA's observations, staff and resident interviews the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, a citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator and appeals right. This is an amended copy of the report previously issued on 10/08/2024. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same. Regarding the allegation: Staff does not ensure bathroom supplies are made available for residents and residents guests. It is being alleged that the bathrooms do not have any soap for anyone to wash their hands and also no paper towels to dry their hands. During LPA's tour, LPA toured four (4) bathrooms and all four (4) bathrooms had soap and towels to dry hands. LPA interviewed four (4) staff and all four (4) staff confirmed that there is soap and towels in all the bathrooms. LPA was only able to interview one (1) out of (5) five residents. One (1) resident confirmed that there is soap and towels in the bathrooms. Therefore, based on the LPA's observations, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 31-AS-20241007141113

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 8, 2024

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: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met by: Based on the observations and interviews the licensee did not ensure one out of five residents at the above facility to receive visitation rights which poses an immediate Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: The Licensee/Administrator will allow all visitors to visit the above facility unless there is a health and safety issue and is to notify LPA Saucedo immediately if this occurs. POC 10/09/24

Type of visit: Required - 1 Year

On 04/27/24 at 8:25AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Anabelle Pascua and disclosed the purpose of the visit. Thresiamma Mathew the licensee arrived about forty (40) minutes later. LPA asked for the census, resident, and staff files. A physical tour was conducted at 9:40 AM and observed the following: The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. There is one (1) refrigerator and one (1) pantry area with extra food. The kitchen area was clean at the time of the tour. Under the kitchen sink the knives and chemicals are kept locked and inaccessible to the residents. On your right-hand side of the kitchen the fire extinguisher is located fully charged with an expiration date of May 2024. Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does has a signal system. The facility does not have a pool or any bodies of water. The outside/backyard can be accessed from the dining/living room area and hallway area. There is two sheds in the backyard with resident property and extra wheelchairs and bedding. The washer and dryer are located outside in the backyard. By the washer and dryer there are two doors where there is access to one (1) storage area and one (1) office. LIC 809C-continued Bedrooms: There are seven (7) bedrooms and four (4) bathrooms. Two (2) of the seven (7) bedrooms have private bathrooms. One (1) of the seven (7) bedrooms is used as a staff room. There are six (6) resident's rooms, one (1) is currently vacant. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 115-118-degree Fahrenheit. There is extra linen in the hallway. The medication is locked and inaccessible to the residents in the hallway on the top shelf. The first aid is kept under the medication shelf also in the hallway. The dining/living room area has enough seating for the residents and the staff. The dining room area has a television, internet access and a telephone. The house temperature is at 75-degree Fahrenheit. There are several smoke detectors/carbon monoxides (dual) in the dining/living area that are operable. Administrative: There is an annual fee that is due by June in the amount of $495.00. At the entrance of the facility on your right-hand side there is door with extra PPE items, administrator License certificate, Yes, Emergency/Disaster Plan, Home Rules and Rights of Individuals, Theft and Loss Policy, Emergency Contacts and the surety bond is updated. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Apr 27, 2024

Allegation investigated: Licensee abandoned the facility Licensee did not follow proper transfer/sale guidelines. Unlicensed care is being provided

Licensing Program Analysts (LPAs) Ray Comer, Gary Tan and Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPAs met with the licensee/administrator, Thresiamma "Tracy" Mathew, and advised her of the complaint. According to the administrator, current license to this address is still valid. There was never a change in ownership. Licensee never abandoned the facility. Licensee did admit that she placed her other facility on Hiawatha (facility #197609741) on sale. Community Care Licensing (CCL) was notified of this on 10/30/23. The administrator stated currently there are five residents living in the home. Four (4) of the five residents are unaware of their surroundings due to their diagnosis. One (1) of the five residents confirms facility is never abandoned and is not notified or ever even aware of any change in ownership. This agency has investigated the above allegations. We have found that the complaint was unfounded, meaning that the allegations are false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and copy of this report issued Unfoundedthe state’s words, verbatim · CDSS document, Apr 18, 2024 · control 31-AS-20240410144308