011441117-8-4-2022-15-AS-LFII-CGYP23-20220804105515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 011441117
Report Date: 08/04/2022
Date Signed: 08/04/2022 10:55:28 AM

Document Has Been Signed on 08/04/2022 10:55 AM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	TRI-CITY RESIDENTIAL CARE HOME		FACILITY NUMBER:	011441117
ADMINISTRATOR:	BANAGA, CONSUELO		FACILITY TYPE:	735
ADDRESS:	4653 SERRA AVENUE		TELEPHONE:	(510) 796-7707
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 6		CENSUS: 6	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Consuelo Banaga- Administrator		TIME COMPLETED:	10:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On today’s date at 9:00 AM, Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct an infection control visit. LPA and LPM was greeted by Care staff- Lydia Ainza. Later, was greeted by Administrator- Consuelo Banaga and explained the purpose of the visit. LPA and LPM toured facility with Lydia- care staff including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed in bathrooms. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Temperature of facility is maintained at 77 degrees F. Water temperature was measured at 107.2 Degree F. Fire extinguisher was last services on 3/23/2022. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Continue on Lic809-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TRI-CITY RESIDENTIAL CARE HOME	FACILITY NUMBER: 011441117
	VISIT DATE: 08/04/2022

NARRATIVE

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Continued on Lic809-C

The following deficiency was observed during inspection:

At 9:13AM, LPA and LPM observed gardening tools such as a Shovel, paints, and pitch fork which is a health and safety risk for persons in care.

The following forms are to be updated and submitted to CCLD By 8/11/2022.

- LIC500- Personnel Report
- LIC308- Designation of Administrative Responsibility

Exit interview conducted and a copy of this report provided along with Appeal rights.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 10:55 AM - It Cannot Be Edited

Created By: Liridon Fici On 08/04/2022 at 10:37 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TRI-CITY RESIDENTIAL CARE HOME	FACILITY NUMBER: 011441117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)(1)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above in having a shed with gardensing tool such as a Shovel, paint cans, and a pitch forks, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Care staff locked up shed during today's inspection. Deficiency Cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Yvonne Flores-Larios

LICENSING EVALUATOR NAME:

Liridon Fici

LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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