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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200684
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:28:16 PM


Document Has Been Signed on 12/21/2023 03:28 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:TRINITYVILLE, INC.FACILITY NUMBER:
019200684
ADMINISTRATOR:RIOS, VIRGINIAFACILITY TYPE:
740
ADDRESS:3731 JOAN AVENUETELEPHONE:
(925) 332-5709
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 5DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Virginia Rios, AdministratorTIME COMPLETED:
03:45 PM
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On 12/21/2023 at 1:30 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Virginia Rios and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory which 1 may be Bedridden.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms were measured at 105.7 degrees Fahrenheit and 106.4 degrees Fahrenheit Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day 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 detectors were in operating condition during visit. First aid kit was observed to be complete. Fire extinguisher was last serviced on 06/06/2023. Fire drill was last conducted on 10/04/2023.

At 1:50 PM, LPA reviewed 5 of 5 residents records. At 2:15 PM, LPA reviewed 3 of 3 staff records and 3 of 3 have current first aid training and associated to the facility. At 2:50 PM, LPA reviewed a sample of 5 of 5 resident’s medications.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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