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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202373
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:14:17 PM

Document Has Been Signed on 12/11/2023 03:14 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
Lookup Error,
, CA
FACILITY NAME:TRINITY RCF, INC.- WILLIAMSFACILITY NUMBER:
435202373
ADMINISTRATOR:INI O. OR OKON A. UBOHFACILITY TYPE:
735
ADDRESS:1330 MICH BLUFF DRIVETELEPHONE:
(408) 476-8772
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 5DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Natividad Barbadillo, staffTIME COMPLETED:
03:30 PM
NARRATIVE
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On 12/11/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit, and requested to meet with the Administrator. LPA met with staff Natividad Barbadillo. Staff was unable to reach Administrator. LPA toured facility with staff. One client was present upon LPA arrival and left on outing during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature was maintained at 22 degrees F and freezer at -10 degrees F. Medications were observed locked in cabinet in dining area. MARs were reviewed. Fire extinguisher was observed with a purchased date of: 1/24/23. Cleaning supplies and chemicals stored in garage cabinet. Bleach bottle and detergent was observed unlocked in the garage.

All bedrooms were observed to have the required furnishings and with adequate lightening. LPA and staff observed a medication cream in bedroom 3 unlock.The bathrooms were properly equipped and operating. Hot water temperature was tested at 110.2 degrees F in bathroom.Outside of facility toured and observed to be free of debris. At approximately 1:32 PM, LPA and staff observed side gate locked. Gardening tools was observed under outdoor seating unlocked.

All clients’ files were reviewed to have all the required documents. Sample of Staff files were also reviewed and observed to have all required documents. Carbon monoxide and smoke detectors were tested and observed to be operational.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.Exit Interview conducted. A copy of this report and appeal rights was provided to staff, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 12/11/2023 03:14 PM - It Cannot Be Edited


Created By: Mai Yang On 12/11/2023 at 02:55 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
,
, CA

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS
FACILITY NUMBER: 435202373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
80075(k)(1) The following requirements shall apply to medications which are centrally stored: Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, at approximately 1:22 PM, LPA and staff observed a R1’s medication Diclofenac cream in R2’s bedroom unlocked which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 12/12/2023
Plan of Correction
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Staff immediately removed medication and locked in facility office. POC cleared during visit.

Type A
Section Cited
CCR
80087(g)
80087(g) Buildings and Grounds Disinfectants, cleaning solutions, poisons, firearms and other items that 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, the licensee did not comply with the section cited above, when LPA and staff observed laundry detergents and a bleach bottle in the garage stored unlocked. LPA and staff observed in the backyard gardening tools stored unlock under an outdoor seating storage. One ambulatory client was present when chemicals and gardening tools were observed unlocked which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 12/12/2023
Plan of Correction
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Staff immediately removed laundry detergents and bleach bottle into lock cabinet in the garage. Staff immediately locked outdoor seating storage. POC cleared during visit.
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2023 03:14 PM - It Cannot Be Edited


Created By: Mai Yang On 12/11/2023 at 02:57 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
,
, CA

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS
FACILITY NUMBER: 435202373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)
80077.3(a) if a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, when LPA and staff observed the facility side emergency exit door locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Staff immediately removed the lock from the locked exit door. POC cleared during visit.
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
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