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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601207
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:07:05 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2021 and conducted by Evaluator Carol Fowler
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210210151048
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:
11/02/2021
UNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Eva Panas CaregiverTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility failed to seek emergency medical treatment for resident in care
INVESTIGATION FINDINGS:
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On 11/02/2021, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to deliver findings on the above allegation. LPA met with Eva Panas Caregiver.
During the course of investigation, LPA L. Fontanilla obtained the following records: Lic 500, incident report, death certificate, Durable Power of Attorney , Healthcare Directive, Lic 601, photocopies of text messages and email from R1’s family members. On 2/11/2021, LPA interviewed Administrator and on 7/1/2021, LPA interviewed Staff 1(S1)
Based on interview conducted with S1 and Administrator, they both suggested to R1’s daughter to send R1 to the hospital due to the decline in condition. However, R1’s daughter refused due to the high number of Covid 19 cases in the hospitals.
Administrator states that R1’s daughter came to the facility at around 9pm of 1/3/2021 and requested to stay for the night to watch over R1 due to labored breathing. LPA verified from the copy of text messages sent by R1’s daughter to Administrator that R1’s daughter is aware that R1 was experiencing labored breathing.
Continuation on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 2
Control Number 15-AS-20210210151048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CARE HOME
FACILITY NUMBER: 015601207
VISIT DATE: 11/02/2021
NARRATIVE
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And that the daughter will stay “that way no one has to come in and check on R1”

R1’s daughter called 911 for R1.

Based on interviews and records review conducted, the above allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.



There is no deficiency noted.

A copy of this report was provided to the Administrator/Caregiver.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2