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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441117
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:04:37 PM

Document Has Been Signed on 07/25/2024 01:04 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TRI-CITY RESIDENTIAL CARE HOMEFACILITY NUMBER:
011441117
ADMINISTRATOR/
DIRECTOR:		BANAGA, CONSUELOFACILITY TYPE:
735
ADDRESS:4653 SERRA AVENUETELEPHONE:
(510) 796-7707
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Constancio Ainza, Direct SupportTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 7/25/2024 at 10:45am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Constancio Ainza, Direct Support, and explained the purpose of the visit. The Administrator, Consuelo Banaga, arrived at 11:50am. The Administrator currently holds a certificate (#6002391735) that expires on 04/06/2025. The facility’s fire clearance was approved for two (2) ambulatory and four (4) non-ambulatory clients. There were no clients present during visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of six (6) bedrooms and two (2) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 102.0 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During visit LPA observed where patio shows on sketch facility is having a gazebo built. LPA was told it would not be a enclosed in room.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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: 07/25/2024
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 2/22/2024. Emergency disaster plan last updated 7/30/2022. Fire drill last conducted 5/1/2024. First aid kit was observed to be complete.

LPA reviewed five (5) staff and five (5) client records all were current, and complete. LPA reviewed P&I.

The following forms to be updated and submitted to CCLD by 8/1/2024:
  • LIC610D Emergency disaster plan (last page)
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • Updated facility sketch


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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