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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602573
Report Date: 06/07/2022
Date Signed: 06/07/2022 05:04:47 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210401102029
FACILITY NAME:TRINITY HOMESFACILITY NUMBER:
198602573
ADMINISTRATOR:AYOARIYO, GEORGEFACILITY TYPE:
735
ADDRESS:17505 HARWICK CTTELEPHONE:
(310) 753-3777
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:4CENSUS: DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:George AyoariyoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff not providing adequate supervision to residents in home.
Home is in disrepair.
Staff not making sure the resident is taking his medication.
INVESTIGATION FINDINGS:
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On 6/7/22, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with George, Administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 4/8/21 LPA Brown tour the physical plan. All Clients were present at the facility and appeared to be fine. LPA requested the following documents: Staff & Resident Roster, Client (C1’s) file Emergency contact, most recent physician report/needs and service/notes/medical assessments & Mars records, all staff training records, Incident reports and repair jobs pertaining to the allegation.

The investigation revealed the following:

LIC9099-C is on the next page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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 4
Control Number 11-AS-20210401102029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TRINITY HOMES
FACILITY NUMBER: 198602573
VISIT DATE: 06/07/2022
NARRATIVE
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Regarding allegation: Staff not providing adequate supervision to residents in home.

On 4/8/21, LPA conducted interview with administrator Ayoariyo regarding the above allegation, he stated there is two staff at the facility and he is also there. He stated had no concern with residents being supervised. He stated client c1 has awol several times and police/incident reports have been made. LPA reviewed c1’s incident reports on 4/20/20,7/20/20.11/16/20,1/17/21/1/24/21,3/19/21 and 3/21/21. LPA reviewed c1 needs & service and stated client requires constant supervision and requires guidance. LPA was unable to interview clients and staff due to them no longer being at the facility. Based on review of the documents, the Administrator did not provide adequate supervision, therefore the allegation is substantiated.

Regarding allegation: Home is in disrepair.

On 4/8/21, LPA conducted interview with administrator Ayoariyo regarding the above allegation, he stated when client c1 had awol he would jump the fence into the neighbor’s property and as a result the fence was damaged and there was debris. LPA reviewed the facility pictures and saw damages to the fences and debris from the wood. On 4/13/21 LPA obtained additional copies of the wood fence and it was repaired. LPA was unable to interview clients and staff due to them no longer being at the facility. Based on review of the documentation the home was in disrepair, therefore the allegation is substantiated.

Regarding allegation: Staff not making sure the resident is taking his medication.

On 4/8/21, LPA conducted interview with administrator Ayoariyo regarding the above allegation, he stated clients did not miss taking medication and c1 did not throw medications onto neighbor’s yards. He also stated staff is trained on giving clients medication. LPA reviewed c1 mars and client has missed taking medication on 4/13/21 at 3 pm. LPA was unable to interview clients and staff due to them no longer being at the facility. Based on review of the documentation staff did not make sure medication was taken, therefore the allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit Interview Conducted, appeal rights were explained, and a copy of this report was furnished to George Ayoariyo.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20210401102029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TRINITY HOMES
FACILITY NUMBER: 198602573
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
06/15/2022
Section Cited
CCR
85075(a)(b)
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85075 Health-Related Services
(a) In addition to Section 80075, the following shall apply. (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
This requirement was not met as evidenced by:

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Licensee shall ensure staff receive medication training and submit a plan on how he will ensure clients have taken medications to LPA by poc due 6/15/22.
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Based on observation, interviews and documentation, on 4/13/21 Licensee did not ensure c1 had taken medication.
This is an immediate health and safety risk to clients in care
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Under Appeal
Type B
06/14/2021
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision
(a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This requirement was not met as by:
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.Licensee will review regulation and send a plan outlining how he will provide adequate supervision to meet the clients in care to LPA by poc due date 6/14/22.
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Based on observation and interviews conducted, Licensee did not ensure client c1 had constant supervision.

This is a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20210401102029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TRINITY HOMES
FACILITY NUMBER: 198602573
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
06/07/2022
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as by:
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Licensee stated gate was damage and has repaired backyard gate. Proof was sent to LPA sent on 4/13/21.
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Based on observations and interviews conducted, Licensee did not ensure facility gate in good repair.

This is a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4