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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002711
Report Date: 11/03/2021
Date Signed: 11/03/2021 12:19:18 PM

Document Has Been Signed on 11/03/2021 12:19 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TRINITY CARE HOMEFACILITY NUMBER:
347002711
ADMINISTRATOR:ENRIQUEZ, HELENFACILITY TYPE:
740
ADDRESS:9513 WADENA WAYTELEPHONE:
(916) 683-9096
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Helen EnriquezTIME COMPLETED:
12:25 PM
NARRATIVE
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On 11-3-21 at 8:30am Licensing Program Analyst (LPA) Tirzah Hubbard arrived unannounced to conduct a Required – 1 Year inspection. LPA contacted the facility to ask follow up questions in regard to Covid-19. LPA left a message for call back at the facility. LPA attempted to enter the facility. LPA observed movement in the facility, but no one would come to the door to let LPA in for visit. LPA contacted the facility Licensee to ask follow up questions for Covid-19 symptoms. LPA notified the licensee that neither staff of the facility opened the door. LPA Hubbard had to wait outside for 45 minutes before entry. LPA proceeded to approach the facility to conduct the Annual after the facility was cleared. All required COVID measures were observed. LPA observed S1 wearing mask upon entry. S1 took the temperature of LPA and asked Covid-19 screening questions. LPA were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents.

All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing. LPA observed the facility conducts fire drills monthly. All bedrooms contained a dresser, bed, and night stand. The flooring of the facility is in the process of repair a this time. The flooring of the kitchen is in disrepair a this time. LPA observed in kitchen area the hood over stove accumulating grease and dirt. Licensee state this will be replaced by 11-12-21.LPA observed in bedroom 1 leaks in the ceiling. Licensee Helen stated the leak has been there since October 24, 2021 from the previous heavy rain. Licensee stated someone will be coming out on 11-3-2021 to fix the ruff and walls of the room. Licensee stated the ruff inspector is currently at their home working on their ruff down the street of the facility. The repair for facility will happened today on 11-3-21 when they are finished at my home. Licensee was not able to provide proof of invoice of repair in process. LPA stated proof of correction can be sent via email by pictures by date 11-5-21. Licensee stated, R1 has still been sleeping in the room and will relocate her today on 11-3-21 until it is fixed. LPA observed in bathroom 2 faucet knob in disrepair containing plastic wrapped around with rubber bands not working. Residents are not able to use the faucet. Licensee did not provide reasoning of why the faucet has been broken. LPA observed the thermostat temperature inside the facility hallway was measured at 75 *F which is within the require range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 108 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TRINITY CARE HOME
FACILITY NUMBER: 347002711
VISIT DATE: 11/03/2021
NARRATIVE
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The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

LPA observed the backyard area in good condition containing old wheel chairs and trash stored in corner of backyard. LPA gave technical assistance in regards to trash in the backyard. Licensee stated, trash pick up day will be scheduled for next week. Licensee will show proof of scheduled pick up date on 11-5-21.

LPA notified Licensee that the trash needs to be taken care by 11-11-21 with follow up email showing proof the trash is gone from both locations of the facility.

Mitigation Plan was submitted and approved.

Upon a file review the following items were discussed to be submitted with any changes annually:

Criminal Record Clearances LIC508
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager- Administrator certificate
Emergency Disaster Plan LIC610D

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, there were deficiencies cited during this visit. Exit interview held and a copy of report was provided in email for signature from licensee and copies faxed and emailed back.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/03/2021 12:19 PM - It Cannot Be Edited


Created By: Tirzah Hubbard On 11/03/2021 at 11:33 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TRINITY CARE HOME
FACILITY NUMBER: 347002711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 the kitchen flooring in disrepair and hood of over the stove accumulating grease which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee will place an order for the repair of kitchen flooring and send proof to LPA Hubbard via email to indicate the time of repair. Licensee stated the hood over the stove will be replaced by 11-5-2021 and will send proof via email with pictures showing the repair.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

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 R1 room contained leaks from the ceiling due to rain on 10-24-21. R1 has been sleeping in the room with the leaks which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee stated the ruff will be repaired on 11-3-21 and will send pictures of wall repair from leak via email and fax. R1 will be relocated to vacant room 4 on 11-3-21 until repair is completed by 11-5-2021.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/03/2021 12:19 PM - It Cannot Be Edited


Created By: Tirzah Hubbard On 11/03/2021 at 11:33 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TRINITY CARE HOME
FACILITY NUMBER: 347002711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 the window screen in backyard of right of facility in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee stated they will replace the window screen by 11-5-21 and show proof of correction by 11-5-21 via email with pictures.
Type B
Section Cited
CCR
87303(e)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:

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 bathroom 2 contained a facet knob in disrepair containing plastic wrapped around it with rubber bands not working and able to use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee will replace faucet knob and fix plumbing to ensure residents can use the bathroom sink by 11-5-2021.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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