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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601207
Report Date: 10/23/2022
Date Signed: 10/23/2022 11:33:33 AM


Document Has Been Signed on 10/23/2022 11:33 AM - 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 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: 4DATE:
10/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Belen Rodriguez, AdministratorTIME COMPLETED:
11:40 AM
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On 10/23/2022 at 10:45AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator. Belen Rodriguez, and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, backyard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 116.1 degrees Fahrenheit. Fire extinguisher last serviced on 8/04/2022.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file. LPA observed PPE, food, and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2022
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 2


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
VISIT DATE: 10/23/2022
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 10/31/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC601E Emergency Disaster Plan
-Updated copy of facility sketch showing shed in backyard.
-Infection Control Plan LIC9282.

No deficiencies cited during visit.

Exit interview and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2