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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609740
Report Date: 09/01/2026
Date Signed: 09/01/2026 02:08:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2026 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20260825161602
FACILITY NAME:TRACY'S BOARDING CARE - LASSENFACILITY NUMBER:
197609740
ADMINISTRATOR:MATHEW, THRESIAMMAFACILITY TYPE:
740
ADDRESS:17419 LASSEN STTELEPHONE:
(818) 882-4930
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 4DATE:
09/01/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tracy MathewTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Uncleared staff caring and supervising residents
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 31-AS-20260825161602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740
VISIT DATE: 09/01/2026
NARRATIVE
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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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20260825161602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
HSC
1569.17(D)
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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
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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.
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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.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2026 and conducted by Evaluator Tuesday Cabiness
COMPLAINT CONTROL NUMBER: 31-AS-20260825161602

FACILITY NAME:TRACY'S BOARDING CARE - LASSENFACILITY NUMBER:
197609740
ADMINISTRATOR:MATHEW, THRESIAMMAFACILITY TYPE:
740
ADDRESS:17419 LASSEN STTELEPHONE:
(818) 882-4930
CITY:NORTHRIDGESTATE:CAZIP CODE:
91325
CAPACITY:6CENSUS: 4DATE:
09/01/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tracy MathewTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1.Staff does not follow facility food menu
2. Staff are not properly storing food
3. Staff does not provide a comfortable temperature for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness and Licensing Program Manager (LPM) Nichelle Gillyarconducted 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: Staff do not follow the facility’s food menu. 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 the facility primarily served residents canned soup and spaghetti and did not follow a food menu. During the visit, LPA observed a food menu posted on the facility refrigerator. LPA also observed an adequate supply of canned goods, non-perishable food items, and perishable food items available for residents.
(Cont'd LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20260825161602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740
VISIT DATE: 09/01/2026
NARRATIVE
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 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)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20260825161602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRACY'S BOARDING CARE - LASSEN
FACILITY NUMBER: 197609740
VISIT DATE: 09/01/2026
NARRATIVE
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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.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6