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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601207
Report Date: 03/10/2023
Date Signed: 03/10/2023 05:35:17 PM


Document Has Been Signed on 03/10/2023 05:35 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 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:
03/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Eva PenasTIME COMPLETED:
05:45 PM
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On 3/10/2023 at 4:50 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit to verify if an individual is currently employed at the facility. LPA met with Eva Penas and explained the purpose of the visit. LPA spoke with Administrator Belen Rodriguez on the phone. Administrator authorized staff Eva Penas to sign the report.

LPA interviewed Administrator and caregivers Carmen Roxas and Eva Penas. Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed or residing at the facility. Administrator states the employee has not been working at the facility since July 20, 2019. LPA has advised the Administrator to disassociate the individual from their roster and submit an updated LIC 500.

LPA provided Eva Penas a copy of Immediate Exclusion Letter.

Exit interview was conducted and a copy of this report was provided.

"Verification of removal is complete"
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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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