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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002711
Report Date: 08/12/2024
Date Signed: 08/12/2024 12:23:39 PM


Document Has Been Signed on 08/12/2024 12:23 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
08/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Helen EnriquezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation, and observed unrelated deficiencies. LPAs Moleski and Williams met with facility administrator Helen Enriquez and explained the purpose of the visit.

LPAs Moleski and Williams were informed by Enriquez that a resident (R1) during the month of July 2024 ripped out their catheter and lacerated themselves in doing so. The resident was taken to the hospital, according to Enriquez. Enriquez also said that R1 was taken to the hospital on July 19, 2024, and was diagnosed with a fracture to their upper arm. The Community Care Licensing Division (CCLD) did not receive any reports regarding these incidents. Enriquez confirmed that no incident reports were sent to CCLD. In an interview, a staff member (S1) confirmed that R1 had been taken to the hospital for their catheter, and for pain in their arm.

LPA Moleski asked for R1's file. LPA Moleski was told by Enriquez and S1 that R1's file was not present. According to Enriquez and S1, S1 had mistakenly placed R1's file with their belongings when moving out in late July. The whereabouts of the file were unknown to Enriquez and S1.

This facility is being cited per 22 CCR Sections 87211(a)(1)(B) and 87506(e). An exit interview was held with Enriquez. Appeal rights and a copy of this report were left with Enriquez.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/12/2024 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: TRINITY CARE HOME
FACILITY NUMBER: 347002711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2024
Section Cited
CCR
87211(a)(1)(B)

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"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:...

(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision." This requirement was not met as evidenced by:
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Licensee agrees to send in incident reports for these incidents by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews, the licensee did not submit required incident reports after R1 suffered a genital laceration due to a catheter being removed, nor when R1 was sent to the hospital for a fracture of their arm, which poses a potential health, safety, and/or personal rights risk.
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Type B
08/26/2024
Section Cited
CCR87506(e)

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"(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident." This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding record retension, and will provide LPA Moleski with a sign-in sheet for the training by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews, this facility did not retain R1's file after termination of service, which poses an potential health, safety, and/or personal rights risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2