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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601359
Report Date: 03/21/2024
Date Signed: 03/29/2024 08:39:09 AM


Document Has Been Signed on 03/29/2024 08:39 AM - 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:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Belen RodriguezTIME COMPLETED:
04:50 PM
NARRATIVE
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On 3/21/2024 at 10:20 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Wilma Bernal. 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 12:50 pm.

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 68 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 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 3/21/2024.

At around 11:00 am, LPA observed Resident 1 (R1) with wound vacuum. Based on interview conducted, R1 is not able to turn from side to side (bedridden).

LPA reviewed 5 resident files and 4 staff files. All staff are fingerprint cleared and associated to the facility. All staff have current First Aid and CPR training. There are four residents who are diagnosed with Dementia but do not have current medical assessment.

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. Civil penalties in the amount of $1,000.00 are assessed for today's visit.

Civil penalty determination related to serious injury is pending. continuation on Lic 809C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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 6


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: 03/21/2024
NARRATIVE
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Exit interview was conducted and Appeal Rights was provided to Rodriguez.

This is an amended copy of the report issued on 3/21/2024 under Tri City Care Home.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/29/2024 08:39 AM - 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: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(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.

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 retained a resident who is bedridden but facility does not have an approved bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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The Administrator will notify local fire department within 24 hours about the bedridden resident and by POC date, she will submit a request for bedridden clearance to CCL.
Type A
Section Cited
CCR
87615(a)(1)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers).

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 having a resident with stage 2 and unstageable pressure injury which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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During the visit, the resident was admitted to hospice care.
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: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 03/29/2024 08:39 AM - 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: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review], the licensee did not comply with the section cited above in having 4 out of 5 residents with dementia but without an uodated medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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By POC date, Administrator will submit to CCL updated medical assessment of the 4 residents with dementia.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6