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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881279
Report Date: 03/05/2025
Date Signed: 03/05/2025 02:26:43 PM

Document Has Been Signed on 03/05/2025 02:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:TRILLIUM HOMEFACILITY NUMBER:
331881279
ADMINISTRATOR/
DIRECTOR:		OWENS, OMORODIONFACILITY TYPE:
735
ADDRESS:23093 TRILLIUM DRIVETELEPHONE:
(951) 678-9228
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 4CENSUS: 4DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator/House Manager Juanita Sanchez TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On 03/05/2025 at 09:45 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown was greeted by a staff and gained access at the home. Licensee/Administrator Omorodion Owens was contacted and informed of the visit. Administrator/House Manager Juanita Sanchez arrived during the visit. LPA Brown explained the purpose of the visit to Administrator/House Manager Sanchez.

The facility has five (5) bedrooms, three (3) bathrooms, entertainment room, kitchen, dining room, living room, attached garage, laundry room and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medications audit and Personal & Incidental (P&I) audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed two (2) clients during the visit. Two (2) clients were out in the community. There are no obstructions to indoor but LPA Brown observed obstructions to outdoor passageways. Deficiency will be issued. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperature tested at 121.6 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, Visitor Policy, House Rules and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. *** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: TRILLIUM HOME
FACILITY NUMBER: 331881279
VISIT DATE: 03/05/2025
NARRATIVE
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There are no firearms and ammunition in the facility. However, LPA Brown was not granted access to inspect the Office Room during the visit today, 03/05/2025. Deficiency will be issued.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. The outdoor pathways were not free of obstructions as evidenced of multiple wood with visible rusted sharp nails, and other metals in the outdoor passageways. Deficiency will be issued.

Food Service: LPA observed more two (2) day(s) supply of perishable food and more seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: The facility has an updated Liability Insurance, Surety Bond, Emergency Disaster Plan and Infection Control Plan. LPA Brown reviewed four (4) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP), Centrally Stored Medications List/Physician Orders. Per documents review, LPA Brown observed that Client #1 (C1) does not have an approved Restricted Health Care Plan maintained in C1 file. Deficiency will be issued. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that Staff #2 (S2)'s working at the facility with criminal background clearance but the Licensee did not transfer S2 criminal background clearance to the facility prior to employment on 04/2024. Deficiency will be issued and civil penalty of $500.00 will be assessed today and will continue to be assessed of $100.00 per day until corrected.

LPA Brown audited four (4) clients’ medications and LPA Brown observed that Client #1 (C1) two (2) medications were not given per C1's physician's directions. Deficiency will be issued. LPA Brown audited three (3) client's P&I and no issues observed.

Deficienies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC421BG and Appeal Rights were discussed, and copies were provided to Administrator/House Manager Juanita Sanchez.

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SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/05/2025 02:26 PM - It Cannot Be Edited


Created By: Melody Brown On 03/05/2025 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TRILLIUM HOME
FACILITY NUMBER: 331881279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring that the outdoor passageway's free of obstruction as evidenced of multiple wood with visible rusted sharp nails, and other metals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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LIcensee stated to remove the multiple wood with visible rusted sharp nails, and other metals in the outdoor passageway and submit proof to LPA Brown by the Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) completed the required on-the-job training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee stated to submit proof of S3 required training to LPA Brown by the POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/05/2025 02:26 PM - It Cannot Be Edited


Created By: Melody Brown On 03/05/2025 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TRILLIUM HOME
FACILITY NUMBER: 331881279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Client #1 (C1) two (2) medications were given per C1's physician's directions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee stated to train all staff on CCR 80075(b)(5)(B) and submit proof of staff training log to LPA Brown by the Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80092(b)(5)
Restricted Health Conditions
(b) Care for the following health conditions must be provided only as specified in Sections 80092.1 through 80092.11. (5) Insulin-dependent Diabetes as specified in Section 80092.8.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Client #1 (C1) has an approved Restricted Health Care Plan maintained in C1 file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee stated to submit Signed Statement of Understanding on CCR 80092(b)(5) to LPA Brown by the POC due date.
Licensee added to submit a copy of C1's Restricted Health Care Plan to LPA Brown once completed for review and approval.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/05/2025 02:26 PM - It Cannot Be Edited


Created By: Melody Brown On 03/05/2025 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TRILLIUM HOME
FACILITY NUMBER: 331881279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring that hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee stated to regulate the hot water temperature in clients shared bathroom to not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) and submit proof to LPA Brown by the Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring Staff #2 (S2) criminal background clearance to the facility prior to employment on 04/2024 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee submitted S2 Criminal Background Clearance Transfer (LIC9182) to LPA Brown during the facility visit today, 03/05/2025. POC cleared.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/05/2025 02:26 PM - It Cannot Be Edited


Created By: Melody Brown On 03/05/2025 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TRILLIUM HOME
FACILITY NUMBER: 331881279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80044(a)
80044 Inspection Authority of the Licensing Agency (a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5, 1533, 1534, 1538, and 1538.7.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not providing access to the office room during the comprehensive annual inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee stated to grant LPA Brown access to the Office Room by the Plan of Correction (POC) due date.
Licensee stated that a key to Staff Room will be available at all times at the facility.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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