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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601359
Report Date: 06/29/2021
Date Signed: 06/29/2021 04:10:58 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210621142046
FACILITY NAME:TRI CITY CARE HOME IIFACILITY NUMBER:
015601359
ADMINISTRATOR:RODRIGUEZ, BELEN V.FACILITY TYPE:
740
ADDRESS:3416 ISHERWOOD PLACETELEPHONE:
(510) 818-0473
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 4DATE:
06/29/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Belen RodriguezTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not seek medical care for resident in a timely manner.
INVESTIGATION FINDINGS:
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On 06/29/2021 at approximately 1:30pm Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a 10-day initial complaint opening. LPA met with Staff Wilma Bernal. Administrator Belen Rodriguez arrived appoximately at 2:00pm.

During visit, LPA interviewed Administrator and two staff. LPA reviewed Resident R1's medication list and physician's report. LPA reviewed text messages between R1's Responsible Party (RP) and Administrator.


Continued on LIC9099-D...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20210621142046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II
FACILITY NUMBER: 015601359
VISIT DATE: 06/29/2021
NARRATIVE
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Based on interview it was confirmed that R1 fell on 06/12/2021 at approximately 4:00pm and was given Tylenol for the pain by staff. R1's physician and R1's responsible party were not notified on 06/12/2021. Staff did not follow facility protocol and notify Administrator until 06/13/2021. R1's family visited facility on 06/13/2021 and R1's responsible party determined that R1 should go to the hospital. R1 was diagnosed with broken shoulder and hip.

Based on LPA’s interviews and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The deficiency is cited per CCR Title 22. Failure to provide proof of correction by POC date may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210621142046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II
FACILITY NUMBER: 015601359
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2021
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in
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Administrator agrees to conduct a staff training on how residents will be assessed, and how changes in condition will be handled. Plan should include steps for responsible party notification, physician
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obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interview and record review Licensee did not comply with the section cited above. Resident (R1) fell and broke shoulder and hip, and R1 was not taken to the hospital until the following day which poses an immediate health, safety or personal rights risk to persons in care.
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notification, and when to call 911. Licensee will submit staff signatures and agenda to CCL by POC date.
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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: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3