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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881147
Report Date: 10/28/2021
Date Signed: 10/29/2021 08:17:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRINITY WAY ASSISTED LIVING FACILITYFACILITY NUMBER:
331881147
ADMINISTRATOR:HAMILTON LIGON, KIMBERLY DFACILITY TYPE:
740
ADDRESS:7015 COLLEGE PARK DRIVETELEPHONE:
(323) 806-2313
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 0DATE:
10/28/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kimberly HamiltonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst Javier Prieto conducted a pre-licensing inspection with Licensee and administrator Kimberly Hamilton. The inspection was conducted in person with Covid-19 restrictions.

The home is a (4) bedroom, (2) bath home with a living room and kitchen.
Per the approved fire clearance, the licensee is approved for 6 ambulatory residents. Bedrooms are furnished with bed. Bedrooms have adequate lighting for residents’ use. The facility has linens, and towels and a sufficient amount of hygiene products for residents. Fire extinguisher was present and fully charged. The kitchen was observed to have dishes, silverware, pots, and pans. Cleaning supplies are locked and stored in kitchen area. Staff and resident files will be locked in cabinet located in the hallway area. The medications locked and stored in a locked cabinet. Smoke detectors were tested and found to be in working order. The backyard was observed to be fully fenced and had a covered patio with table and chairs for resident's comfort. Documents required are posted in public view were observed to be present.

The Component III Orientation was completed during the pre-licensing inspection.

An exit interview was conducted, and a copy of this report was given to Ms Hamilton for her review and signature
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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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