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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002711
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:54:39 AM

Document Has Been Signed on 11/14/2024 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TRINITY CARE HOMEFACILITY NUMBER:
347002711
ADMINISTRATOR/
DIRECTOR:		ENRIQUEZ, HELENFACILITY TYPE:
740
ADDRESS:9513 WADENA WAYTELEPHONE:
(916) 683-9096
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Elaine EnriquezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with staff member Elaine Enriquez and explained the purpose of the visit.

LPA Moleski reviewed five resident files (R1-R5) and two staff files (S1-S2). S2's most recent first aid/CPR certification expired as of November 3, 2024. S2 said that they were not aware it was expired. LPA Moleski observed that R3's pre-admission appraisal was blank. LPA Moleski spoke with licensee Helen Enriquez over the phone and asked if R3 had a pre-admission appraisal. Helen Enriquez said that she never saw R3 before they were admitted.

LPA Moleski toured the facility with staff and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 112 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed a locked cabinet in the kitchen for the storage of cleaning solutions and knives.

LPAs Moleski and Williams interviewed one staff member (S2) and two residents (R4-R5).

This facility is hereby cited per 22 CCR Sections 87411(c)(1) and 87457(c). An exit interview was held with Elaine Enriquez. Appeal rights and a copy of this report were left with Elaine Enriquez.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/14/2024 11:54 AM - It Cannot Be Edited


Created By: Vincent Moleski On 11/14/2024 at 11:37 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TRINITY CARE HOME
FACILITY NUMBER: 347002711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S2 did not have a current first aid/CPR certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee agrees to acquire updated first aid/CPR certification for S2 by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R3 did not have a pre-admission appraisal completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee agrees to complete a new appraisal for R3 by POC due date.
vincent.moleski@dss.ca.gov
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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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