075600926-3-23-2023-15-AS-LFRO-CQ7T9Q-20230323143220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600926
Report Date: 03/23/2023
Date Signed: 03/23/2023 02:32:40 PM

Document Has Been Signed on 03/23/2023 02:32 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:	TRINITY CARE HOME #2		FACILITY NUMBER:	075600926
ADMINISTRATOR:	LICUP, GINA V.		FACILITY TYPE:	740
ADDRESS:	110 AVOCADO CT.		TELEPHONE:	(925) 719-1548
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 6	DATE:	03/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marjorie Osia, Back-up Administrator		TIME COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/23/2023 starting 10:00 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs were greeted by Caregiver, Jimmy Payna and LPAs explained the purpose of the visit. Back-up Administrator, Marjorie Osia later arrived at 10:30 AM. The facility’s fire clearance was approved for all six (6) residents may be non-ambulatory. There were 5 staff of which 2 were off-duty and 6 residents present during inspection. Starting at 10:45 AM, LPAs toured facility with back-up Administrator including but not limited to 6 bedrooms, 3 bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for residents and 1 bedroom is for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in 1 of 3 residents’ shared bathroom was measured at 115 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 5/7/22. Emergency Disaster Plan was last posted on 1/6/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 1/6/23. *REPORT CONTINUES ON 809C*

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 4

Document Has Been Signed on 03/23/2023 02:32 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: TRINITY CARE HOME #2	FACILITY NUMBER: 075600926
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed S2 is fingerprint cleared, but not associated to the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will submit LIC 9182 and a copy of S3's government issued ID to CCLD.

Type B

Section Cited

CCR

87411(c)(1)

87411(c)(1) Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed S3's first aid training expired in 3/11/2022 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to submit a copy of S3's first-aid training to CCLD

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: TRINITY CARE HOME #2	FACILITY NUMBER: 075600926
	VISIT DATE: 03/23/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At 12:20 PM, LPAs reviewed 5 residents records. At 1:15 PM, LPAs reviewed 3 staff records. At 3:10 PM, LPAs reviewed a sample of resident’s medications.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
-At 10:15 AM, LPAs observed S2 is not associated to the facility
-At 1:38 PM, LPAs observed S3's first-aid cert expired 3/11/22

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4