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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601359
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:18:20 PM


Document Has Been Signed on 03/07/2022 02:18 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 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: 5DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:TIME COMPLETED:
02:50 PM
NARRATIVE
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On 3/7/2022 at 11:30AM, Licensing Program Analysts (LPAs) L. Ibo & L. Fici conducted an infection control annual inspection and explained the purpose of the visit with S2. Administrator arrived at the facility around 12:50PM. LPAs observed 5 residents during the visit. Facility has a completed mitigation plan. LPAs inspected the facility inside and outside. LPAs observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing.

LPAs 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 (F). Bathroom have grab bars and non-skid mat. The facility has appropriate lighting throughout. Extra linens and towels were observed in the hallway closet.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.


Continued on next page LIC 809-C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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 5


Document Has Been Signed on 03/07/2022 02:18 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 II
FACILITY NUMBER: 015601359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


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 side gate was locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2022
Plan of Correction
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Staff unlock side gate
Corrected during the visit.
Administrator will train all staff regarding the citation, proof of training needs to be submitted on CCL office on 3/11/2022.
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


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 medicaition was accesible to residents in care, disinfectant cleaner accessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2022
Plan of Correction
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Staff locked the disinfectant supplies and medications supplies.
Corrected during the visit.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 03/07/2022 02:18 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 II
FACILITY NUMBER: 015601359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.


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 in deck flooring has obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2022
Plan of Correction
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Administrator agreed to fix the deck flooring and replace the wood that has temporary wood patch, Administrator will need to send proof of correction to CCL 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 03/07/2022 02:18 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 II
FACILITY NUMBER: 015601359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(5)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff has not conducted staff training on infection prevention, symptoms, transmission and PPE usewhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Administrator agreed to train all staff regarding infection prevention, symptoms, transmission and PPE use, proof traning need to be submitted to CCL on the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


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 II
FACILITY NUMBER: 015601359
VISIT DATE: 03/07/2022
NARRATIVE
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LPAs observed the following:
· Facility DOES NOT document daily COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility. (technical assistance provided)

· Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use.

· Unlock medications (see LIC809D)

· Unlock cleaning product (comet) under the kitchen sink (see Lic809D)

· Lock side exit gate (see Lic809D)

Civil penalty was assessed during the visit.


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.

Deficiencies and plan and proof of corrections were discussed with Belen Rodriguez

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5