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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441117
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:53:50 PM

Document Has Been Signed on 07/21/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TRI-CITY RESIDENTIAL CARE HOMEFACILITY NUMBER:
011441117
ADMINISTRATOR:BANAGA, CONSUELOFACILITY TYPE:
735
ADDRESS:4653 SERRA AVENUETELEPHONE:
(510) 796-7707
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Consuelo Banaga, AdministratorTIME COMPLETED:
02:55 PM
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On 7/21/2023 starting at 11:50 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Consuelo Banaga, Administrator (ADM) and explained the purpose of the visit. The facility’s fire clearance was approved for 2 ambulatory, and 4 non-ambulatory clients. Upon entry, LPA observed three (3) staff and two (2) clients present during inspection.

Starting at 12:24 PM, LPA toured facility with ADM including but not limited to six (6) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are private, one room is shared, and one staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 77 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 106.9 Degrees Fahrenheit. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Sharps and toxins were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 2/10/2023. First aid kit was observed to be complete.


Continue on Lic809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TRI-CITY RESIDENTIAL CARE HOME
FACILITY NUMBER: 011441117
VISIT DATE: 07/21/2023
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Continued from Lic809

Starting At 12:44 PM, LPA reviewed 3 of 3 staff records. At 1:07 PM, LPA reviewed 2 of 6 clients' record which are current. At 1:32 PM, LPA reviewed a sample of 2 of 6 clients' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/28/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan (9 Pages)
· Liability Insurance
· Surety bond



No deficiencies cited during visit.



Exit interview conducted with ADM, and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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