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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601207
Report Date: 12/05/2024
Date Signed: 12/05/2024 01:32:10 PM

Document Has Been Signed on 12/05/2024 01:32 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/
DIRECTOR:		RODRIGUEZ, BELEN V.FACILITY TYPE:
740
ADDRESS:2438 DOUGLAS STREETTELEPHONE:
(510) 324-0999
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:RODRIGUEZ, BELEN V, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 12/5/2024 at 9:30 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and met with staff care staff, Mathew Aviles. The Administrator was informed over the phone about the purpose of the visit. The Administrator (Administrator cert#6021647740 expiration 12/16/24) arrived at the facility at around 10:15am.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room and outdoor area. The facility’s temperature was maintained at 73 degrees Fahrenheit . Bathroom have grab bars and non-skid mat. The facility has appropriate lighting throughout. Extra linens and towels were observed in the hallway closet. Hot water temperature measured at 115.3 degrees Fahrenheit. There were sufficient supplies of perishable and non perishable foods. First aid kit was observed complete and updated. Fire extinguisher was observed that appeared full and has purchase date of 2/25/2024. Fire Drill last conducted 10/14/24. Emergency disaster plan last updated on 3/21/24. Liability insurance effective 1/17/2024 to 1/17/25. LPA reviewed 6 resident files and 3 staff files. All staff are fingerprint cleared and associated to the facility. All staff have current First Aid and CPR training.

At around 10:15 am, LPA observed cheese, and tomato have mold in the refrigerator. Cleared
At around 10:25am, LPA observed ant, roach, and spider (hot shot) spray inside room 4 bathroom. Cleared
At around 10:40am, LPA observed residents’ medication are not in its original container.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview was conducted and Appeal Rights was provided.

Bennett FongTELEPHONE: (510) 725-7919
Kelly NguyenTELEPHONE: (510) 915-8702
DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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Document Has Been Signed on 12/05/2024 01:32 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: 12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having ant, roach, and spider (hot shot) spray inside room 4 bathroom. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator remove ant, roach, and spider (hot shot) spray inside room 4 bathroom during inspection. Deficency Cleared
Section Cited
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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 by having cheese, and tomato have mold in the refrigerator.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator remove the cheese, and tomato contained mold during inspection. Deficency Cleared
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett FongTELEPHONE: (510) 725-7919
Kelly NguyenTELEPHONE: (510) 915-8702

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2024 01:32 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: 12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in by having residents’ medication that are not in its original container. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Administrator agree to send in proof of med trainging, MAR logs, orgraize original medication of residents containers to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett FongTELEPHONE: (510) 725-7919
Kelly NguyenTELEPHONE: (510) 915-8702

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024

LIC809 (FAS) - (06/04)
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