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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601207
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:36:52 PM


Document Has Been Signed on 04/09/2024 01:36 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: 6DATE:
04/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eva PenasTIME COMPLETED:
02:00 PM
NARRATIVE
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While at the facility delivering finding for complaint #15-AS-20240325163517, LPA observed R1 asking S2 if R1 is able to eat. S2 told R1 that R1 can go ahead and eat lunch.

LPA asked S2 if R1 is diabetic. S2 states R1 is diabetic. When asked if R1 is on insulin, how often R1 needs to check blood sugar and whether R1 is able to check own blood sugar. S2 states R1 is on oral medication and needs blood sugar checked twice a day. S2 states R1 is unable to check own blood sugar. And staff checks R1's blood sugar.

The facility does not have an approved exception.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Penas and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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


Document Has Been Signed on 04/09/2024 01:36 PM - It Cannot Be Edited

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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2024
Section Cited
CCR
87628(a)

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87628 Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional
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By POC date, the Administrator will provide CCL plans on how to address R1's diabetes and submit to CCL.
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This requirement is not met as evidenced by: Based on interview conducted, R1 is diabetic and needs FBS check 2x a day. However, R1 is unable to check own blood sugar. Staff check R1's FBS and facility does not have an approved exception.
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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: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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