Tracy's Boarding Care - Louise

Allegation investigated: Facility staff refused to readmit resident Staff does not ensure resident is dispensed medications as prescribed

On 08/06/25, at 9:14am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by George Siapno, Caregiver. The licensee Thresiamma Mathew was called and arrived about fifteen (15) minutes after. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 08/06/25, at 9:50am, LPA Saucedo asked for the census, staff, and resident rosters. At 10:10am, LPA Saucedo conducted a physical tour, interviewed staff and obtained the following documents-Resident Appraisal, Appraisal/Needs and Services Plan, Admission Agreement and Pre-placement. LIC 9099C-continued Substantiated Regarding the allegation: Facility staff refused to readmit resident. It is being alleged that the administrator of the care home is refusing to take the resident back from the hospital upon discharge. LPA interviewed three (3) staff that confirmed that due to resident #1 (R1)’s behavior, R1 is not being allowed to return back to the above facility. LPA reviewed the facilities admission agreement regarding R1, R1’s pre-placement and resident appraisal. There was no reassessment/updated resident appraisal and/or reappraisals conducted for R1 showing the process of eviction. There was no eviction notice given to the resident, resident’s family and Community Care Licensing Department about not accepting/readmitting R1 back to the facility from the hospital. The pre-placement stated R1 had behavioral problems and agitation at times. The resident appraisal and Appraisal/Needs and Services Plan showed that R1 would have psychosis behavior. Therefore, based on the LPA's record reviews and staff interviews conducted, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff does not ensure resident is dispensed medications as prescribed. It is being alleged that the resident has not been receiving their psychotropic medication(s) at the facility. LPA interviewed three (3) staff that confirmed resident #1 (R1) was provided medication. LPA asked if R1 was being provided their psychotropic medication and staff failed to prove that R1 was being provided psychotropic medication. LPA received pictures of the medication packets from a witness that showed between 07/26/25 to 07/30/25 the medication were still inside of the packets. The medications that were not dispensed/given to the resident were-Divalproex (bipolar disorder) and Quetiapine Fumarate (psychosis). The staff sent R1 to the hospital on 07/30/25 for hitting staff and aggressive behavior. Furthermore, the medication Atorvastatin (to lower cholesterol and triglycerides) was not given to R1. LPA spoke to one (1) of the hospital staff that confirmed R1 was doing well after being provided their psychotropic medication. Therefore, based on the LPA's record reviews/medication review and staff interviews conducted, the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, appeal rights were provided, and a copy of this report was given to the resident care director.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 31-AS-20250731143056

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Aug 7, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement is not met by: Based on the LPA's Interviews the licensee/administrator failed to ensure that resident #1 (R1) was not given the proper 30 (thirty) day notice for eviction. R1 was not allowed back to the facility after hospitalization discharge. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee/Administrator will ensure to send community care licensing department a proper thirty (30) day notice regarding R1 The POC due date: 08/07/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 7, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met by: Based on the LPA's Interviews the licensee/administrator failed to ensure that resident #1 (R1) was being provided all their medication. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee/Administrator will ensure to train all staff on medication management. The POC due date: 08/07/25

Type of visit: Required - 1 Year

On 06/02/25 at 9:35AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver George Siapno and disclosed the purpose of the visit. Thresiamma Mathew the licensee arrived about fifteen (15) minutes later. LPA asked for the census, resident, and staff files. A physical tour was conducted at 10:15AM and observed the following: Bedrooms: There are seven (7) bedrooms and three (3) bathrooms. One (1) of the seven (7) bedrooms is used as a staff room. There are (6) resident’s rooms, two (2) of them are 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 at and non-skid mats. The bathroom temperatures of the water are within regulations reading at 114-116-degree Fahrenheit. Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does have a signal system. The facility does not have a pool or any bodies of water. The pool was removed. The outside/backyard can be accessed from the dining/living room area and hallway area. There is one (1) shed in the backyard used as a storage. The washer and dryer are located outside in the backyard. The chemicals are in the backyard inaccessible to the residents. There is no garage. LIC 809C-continued 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. The kitchen area was clean at the time of the tour. On your left-hand side in one (1) of the shelves the knives and are kept locked and inaccessible to the residents. On your left-hand side of the kitchen the fire extinguisher is located fully charged with an expiration date of April 2026. The medication and first aid are locked and inaccessible to the residents on the top cabinet on your left-hand side. The phone line is in the kitchen. The dining/living room area has enough seating for the residents and the staff. The dining room area has a television and internet access. There are several temperatures throughout the house 72, 78-degree Fahrenheit. There are several smoke detectors/carbon monoxides (dual) in the dining/living area that are operable. There are also fire sprinkers throughout the house. Administrative: There is no annual fee due right now. At the entrance of the facility on your left-hand side there is door with extra PPE items, administrator License certificate, Yes, Emergency/Disaster Plan, Facility Sketch, Rights of Individuals, COVID signs, Resident Council and the surety bond is updated and expires 09/14/25. There is also the Ombudsman sign. There are three (3) dementia residents, two (2) on hospice and there were two (2) staff providing care and supervision. 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, Jun 2, 2025

Type of visit: Required - 1 Year

On 04/28/24 at 8:20AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver George Siapno and disclosed the purpose of the visit. Thresiamma Mathew the licensee arrived about thirty (30) minutes later. LPA asked for the census, resident, and staff files. A physical tour was conducted at 9:05 AM and observed the following: Bedrooms: There are seven (7) bedrooms and three (3) 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 116-119-degree Fahrenheit. Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does have 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 one (1) shed in the backyard used as a storage. The washer and dryer are located outside in the backyard. The chemicals are in the backyard inaccessible to the residents. There is no garage. LIC 809C-continued 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. The kitchen area was clean at the time of the tour. On your left-hand side in one (1) of the shelves the knives and are kept locked and inaccessible to the residents. On your left-hand side of the kitchen the fire extinguisher is located fully charged with an expiration date of May 2024. The medication and first aid are locked and inaccessible to the residents on the top cabinet on your left-hand side. The phone line is in the kitchen. There is also the Ombudsman sign and activity calendar against the wall in the kitchen. The dining/living room area has enough seating for the residents and the staff. The dining room area has a television and internet access. The house temperature is at 78-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. At the entrance of the facility on your left-hand side there is door with extra PPE items, administrator License certificate, Yes, Emergency/Disaster Plan, Facility Sketch, Rights of Individuals, COVID signs, Resident Council 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 28, 2024

Allegation investigated: Resident sustained an unstageable pressure injury while in care

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with the Co-Administrator, Anabel Pascua and explained the reason for today’s visit. On 11/23/2021, the Department received a complaint alleging that Resident (R1) had sustained an unstageable pressure injury while in care. The complaint was referred to the Investigation Bureau (IB) on 11/23/21 but was rescinded due to involvement of Home Health Services for R1. The Department initiated the complaint investigation on 11/24/2021 at 9:43 AM. LPA conducted physical plant tour at 9:45 AM, obtained copies of the facility records relevant to the investigation at 10:00 AM and interviewed the Administrator and Home Health Nurse at 11:00 AM. (continued to LIC 9099-C) Unsubstantiated (continued from LIC 9099) It was alleged that Resident #1 (R1) was discharged from the hospital in September 2021 with Stage two pressure wounds and taken to the board and care. R1 was returned to the same hospital and was admitted on 11/17/21 with unstageable decubitus ulcer of the buttock. LPA’s record review on 04/10/22 of facility, hospital and home health records revealed that R1 was admitted to the facility on 07/31/21 with an initial diagnosis of colon cancer with the recommendation for Home Health for wound assessment, Ostomy Care, Caregiver Teaching and Physical Therapy. R1 was admitted by a home Health agency on 08/02/21 for various health issues including but not limited to a Stage 2 pressure ulcer. On 08/02/21, R1 was assessed by home health wound nurse to have a Stage 2 pressure sore on left buttock. R1 was put on three (3) Home Health nurse visits for the first week and two times a week for the next eight (8) weeks. Further review also revealed that R1 was on home Health services from 08/02/21 up to R1’s last hospitalization on 11/17/21 wherein R1 did not return to the facility and was placed in a Skilled Nursing Facility. Further review also confirmed that caregivers of the facility were educated on how to care for R1’s wound and in general by the Home Health Nurse (HHN). LPA’s interview with HHN on 11/24/21 at around 11:30 AM confirmed that the HHN was at the facility caring for R1 and was the one who called 911 due to R1’s behavior on 11/17/21 when R1 was hospitalized. Further, HHN confirmed training the staff on how to provide care for R1. LPA’s interview with staff on 04/12/22 at 10:52 AM revealed that the staff change R1’s diaper on a regular basis and turned R1 every two (2) hours as instructed. Based on the information gathered during the course of the investigation, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 31-AS-20211123104538