015601207-4-9-2024-15-AS-KHOS-D4ML6U-20240424082918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601207
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:40:04 PM

Substantiated

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
03/25/2024 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240325163517

FACILITY NAME:	TRI CITY CARE HOME		FACILITY NUMBER:	015601207
ADMINISTRATOR:	RODRIGUEZ, BELEN V.		FACILITY TYPE:	740
ADDRESS:	2438 DOUGLAS STREET		TELEPHONE:	(510) 324-0999
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 6	DATE:	04/09/2024
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Eva Penas		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Overcapacity

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day at around 11:55 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding for the above allegation and met with Eva Penas. LPA explained to Penas the purpose of the visit. The Administrator was out of the facility and authorized Penas to sign the report.

On 3/28/2024, LPA conducted initial 10-day visit, obtained records and interviewed the Administrator and Staff 2 (S2). On 4/2/2024, LPA reviewed records and Guardian.

Based on interview conducted on 3/28/2024, the Administrator states that Witness 1 (W1) has been staying at the facility in one of the staff rooms since December 12, 2023. The Administrator states that W1 is temporarily staying at the facility because W1 has issues and that W1 will be leaving on April 11, 2024. The Administrator added that W1 is fingerprint cleared and associated to the facility. The Administrator states that W1 is paying $1,000/month for food and utilities but the facility does not provide care because W1 is independent.
continuation on Lic 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20240325163517

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	FACILITY NUMBER: 015601207
	VISIT DATE: 04/09/2024

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

Based on interview conducted with S2, S2 confirmed with LPA that W1 has been staying in one of the caregiver rooms since December 2023. S2 states W1’s husband comes every day to pick up W1 and would bring back W1 at the end of the day. S2 added that if W1 would use the bathroom, S2 states W1 does not need a lot of assistance but S2 would make sure that W1 is safe due to W1’s knee surgery. S2 added that there were times that S2 would assist W1 while using the bathroom.

A review of Guardian shows W1 associated to the facility on 12/12/2023 as an employee. However, the facility’s Lic 500 does not indicate that W1 is one of the employees at the facility.

Despite the Administrator’s denial that W1 is a resident, the facility’s license allows the facility to admit/retain six (6) residents only. And the fact that W1 pays $1,000/month, is not listed in Lic 500 as an employee and that S2 does provide assistance to W1 on as needed basis are sufficient evidence to substantiate the allegation “Over capacity.”
Based on interviews and record review conducted, the above allegation is substantiated.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is cited on the attached LIC 9099D.

Civil penalty in the amount of $500.00 is assessed for today's visit.

Exit interview was conducted and Appeal Rights was provided to Penas.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20240325163517

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	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 04/09/2024 Section Cited CCR 87204(a)	1 2 3 4 5 6 7	87204(a) Limitations - Capacity and Ambulatory Status (a)(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.	1 2 3 4 5 6 7	During the visit, LPA was informed by the Administrator that W1 has moved out of the facility on 3/29/2024. Civil penalty of $500 is assessed for today's visit.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: The facility admitted W1 temporarily while recovering from surgery despite at full capacity which poses an immediate risk to the health and safety of clients.	8 9 10 11 12 13 14
Type A 04/10/2024 Section Cited CCR 87203	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	The Administrator states W1 moved out of the facility on 3/29/2024. The Administrator will submit self-certification of understanding of Sections cited and submit to CCL by POC date.
	8 9 10 11 12 13 14	Based on interviews conducted, the facility failed to comply with State Fire Marshall regulations when the facility admitted W1 who was recovering from surgery and stayed in one of the caregivers' room which poses an immediate risk to the health and safety of clients under care.	8 9 10 11 12 13 14

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-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3