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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601207
Report Date: 09/03/2020
Date Signed: 09/03/2020 04:41:58 PM

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 CARE HOMEFACILITY NUMBER:
015601207
ADMINISTRATOR:RODRIGUEZ, BELEN V.FACILITY TYPE:
740
ADDRESS:2438 DOUGLAS STREETTELEPHONE:
(510) 324-0999
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
09/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Belen RodriguezTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management televisit via Facetime with
Administrator Belen Rodriguez. LPA explained to Administrator the purpose of visit. LPA informed Administrator that the visit is being conducted via Facetime due to the shelter in place order of the governor and telework directive of management.

LPA informed Administrator that CCL received a report stating that she allowed staff 1 (S1) who tested positive for Covid 19 to work at the facility. The report indicated that staff were informed by Administrator that S1 completed the 14 day quarantine period. However, report indicates that S1 does not remember when she first had the symptoms. Administrator states that she did allow one of her former caregivers to work at the facility last 8/31. Administrator states that S1 did test positive for Covid 19 and that S1 has completed the 14 day quarantine period. Administrator provided LPA a copy of S1's note from the clinic that conducted the testing.
The note states that S1 tested positive on 8/7/2020 and since she has self-isolated for 10 days beyond the positive test date and her symptoms have resolved, she may return to work effective 8/18/2020. S1 worked at this facility on 8/31/2020.

There is no deficiency noted.

A copy of this report will be provided to Administrator via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020
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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