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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601207
Report Date: 12/20/2021
Date Signed: 12/20/2021 12:53:25 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:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Carmen Roxas, CaregiverTIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/20/2021 at 9:30 AM, Licensing Program Analysts (LPAs) L. Holmes and C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs met with Carmen Roxas, Caregiver and explained the purpose of the visit. Administrator, Belen Rodriquez was called about 15 minutes after visit started and advised would arrive later. Licensee arrived at 12:00 pm.

Upon entry, LPA's temperatures were checked. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, outdoor areas and garage. LPAs observed some sign & symptoms, cough etiquette, and social distancing that were posted in the common and hallway areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs for both residents and staff. A copy of the Mitigation Plan is on file. LPAs observed some PPEs, food, and paper supplies that are sufficient.

The following deficiencies were observed during the visit:
-At 9:55 am, LPAs observed unlocked knife. At 10:04 am, unlocked vitamins. At 10:20 am, unlocked cleaning supplies were observed in the unlocked garage. At 10:25 am, an unlocked shed with gardening tools was observed in the backyard.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 7
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 CARE HOME
FACILITY NUMBER: 015601207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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Caregiver corrected deficiency during inspection. Knife was removed from kitchen dish drain and locked inside the locked sharps drawer.
Licensee corrected deficiency during visit. Licensee locked shed in the backyard.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervsiion of the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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Licensee corrected deficiency during the inspection. Observed cargiver lock the medication in the hallway medication closet on 12/20/21.
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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7
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 CARE HOME
FACILITY NUMBER: 015601207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
(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
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2
3
4
Based on observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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2
3
4
Caregiver corrected deficiency during the inspection. Observed cargiver lock the cleaning supplies in garage cabinet on 12/20/21.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7