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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002711
Report Date: 10/30/2023
Date Signed: 10/30/2023 12:01:58 PM


Document Has Been Signed on 10/30/2023 12:01 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 AC/SC, 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:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Helen EnriquezTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Helen Enriquez and explained the purpose of the visit.

LPA Moleski reviewed five resident files (R1-R5) and two staff files (S1-S2).

LPA Moleski toured the facility with Enriquez 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 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed cabinets for the storage of medication. LPA Moleski observed cabinets for the storage of cleaning solutions and knives.

While inspecting the facility, LPA Moleski and Enriquez observed unsecured cleaning solutions, including bleach, left in unlocked cabinets in two bathrooms. LPA Moleski and Enriquez observed unsecured laundry detergents left in unlocked cabinets in a hallway. All cleaning solutions and detergents observed were placed in locked cabinets during this visit.

LPA Moleski interviewed two staff members (S1-S2). Residents were not available to be interviewed.

This facility is being cited per 22 CCR Section 87309(a). An exit interview was conducted and appeal rights and a copy of this report was left with Enriquez.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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 10/30/2023 12:01 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: TRINITY CARE HOME
FACILITY NUMBER: 347002711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions were left unlocked and accessible in two facility bathrooms and a hallway cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Staff moved cleaning solutions into locked storage areas during this visit. This plan of correction will be cleared.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2