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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600123
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:49:50 PM

Document Has Been Signed on 12/16/2024 05:49 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:TRINITY ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
374600123
ADMINISTRATOR/
DIRECTOR:		TRINIDAD M. DELA ROSAFACILITY TYPE:
735
ADDRESS:8 TOURMALINE STREETTELEPHONE:
(619) 271-9409
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 12CENSUS: 12DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Licensee Trinidad Dela Rosa and Caregiver Frederico "Eric" RamosTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Trinidad Dela Rosa and Caregiver Frederico "Eric" Ramos.

Interviews of Licensee and facility staff showed that for at least five (5) workdays, Licensee briefly employed Staff #1 (S1) as a caregiver of the facility to cover another caregiver’s vacation. [See LIC811 Confidential Name List for identification of select person identifiers used in this report.] A review of CCLD’s Guardian Database showed that while S1 possessed an active background clearance with CCLD to work with clients, Licensee did not ensure that S1 was associated to the facility’s employee roster, as required. By the date of CCLD’s identification of the issue, S1 was no longer working at the facility.

CCLD requested a copy of the facility’s dated employee time/work schedule for the month of September 2024. Licensee replied that they did not maintain any such schedule at the facility (which was required by regulation).

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Since one of the deficiencies is an employee background violation, a Background Check Civil Penalty (BCCP) of $500 was assessed/charged to Licensee (refer to the LIC421-BG page). Since the facility will be closing and ceasing operations today, no Plan of Correction was formed with Licensee.

An exit interview was conducted with Dela Rosa and Ramos, to whom a copy of this report, the LIC 9099-D page, the LIC421-BG page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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 12/16/2024 05:49 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/16/2024 at 02:07 PM
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
, 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: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2024
Section Cited
CCR
80019(e)(3)

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80019 Criminal Record Clearance: “(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f)…” This requirement was not met, as evidenced by:
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By the date of CCLD’s identification of the issue, S1 was no longer working at the facility. Since the facility will be closing today, no Plan of Correction was formed with the Licensee.
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Based on records and manager interview, Licensee did not ensure that 1 of 5 staff (S1), who was subject to a criminal record review pursuant to Health and Safety Code Section 1522, requested and received a transfer of criminal record clearance, prior to working at the facility. This posed a potential safety risk to 10 of 10 clients (C1 through C10) in care.
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Type B
12/16/2024
Section Cited
CCR85066(b)

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85066 Personnel Records: “(b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference…” This requirement was not met, as evidenced by:
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Since the facility will be closing today, no Plan of Correction was formed with the Licensee.
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Based on LPA observation and staff interviews, Licensee did not ensure that a dated employee time schedule was developed at least monthly and displayed conveniently for employee reference. This posed a potential health, safety, and personal rights risk to 10 of 10 clients (C1 through C10) in care.
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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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