374600123-11-20-2023-08-AS-AROS-CXRR76-20231120114549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600123
Report Date: 11/20/2023
Date Signed: 11/20/2023 11:45:58 AM

Document Has Been Signed on 11/20/2023 11:45 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	TRINITY ADULT RESIDENTIAL CARE HOME		FACILITY NUMBER:	374600123
ADMINISTRATOR:	TRINIDAD M. DELA ROSA		FACILITY TYPE:	735
ADDRESS:	8 TOURMALINE STREET		TELEPHONE:	(619) 271-9409
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY:	12	CENSUS: 10	DATE:	11/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	care giver Federica Ramos		TIME COMPLETED:	11:55 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection to ensure substantial compliance with Title 22 regulations. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Care Giver Federico Ramos and Licensee Trinidad Dela Rosa. According to the facility’s license, the facility has a maximum capacity of twelve (12) residents, all of which are ambulatory. During today’s inspection, there were a total of ten (10) clients in care. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each common area and resident rooms. The resident rooms were clean and in adequate repair. The two common bathrooms were clean and in adequate repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. doors and windows which were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Refrigerator temperature and freezer temperature were compliant. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential medical records were stored in locked areas. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 11/20/2023 11:45 AM - 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TRINITY ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 374600123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in4 of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	Called First Aid company to make appointment while LPA was present

Type B

Section Cited

HSC

1565(a)

Other Provisions

(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Will complete all information for updated disaster plan by plan of correction 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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TRINITY ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 374600123
	VISIT DATE: 11/20/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit and first aid supplies were complete and readily accessible. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet residents’ needs.

LPA interviewed clients and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The client files which LPA reviewed contained required documents. Licensee Trinidad Dela Rosa could not presented proof of current/active business liability insurance.

Staff records review verified that all staff records were not complete and compliant. All the direct care staff did not have First Aid certificates. There is not a current written disaster plan in place at the facility.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with Licensee Trinidad Dela Rosa. An exit interview was conducted with Licensee Trinidad Dela Rosa to whom copies of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the Licensee Trinidad Dela Rosa

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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