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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202513
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:51:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2021 and conducted by Evaluator Christine Dolores
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211222155702
FACILITY NAME:TREBOL HOME INC.FACILITY NUMBER:
435202513
ADMINISTRATOR:KIEN LINHFACILITY TYPE:
735
ADDRESS:3251 TREBOL LANETELEPHONE:
(408) 622-3299
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tammy LuTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility refused to take resident back
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced visit to deliver the finding of the above allegation. LPA met with Administrator in training, Tammy Lu.

From 12/29/2021 – 02/02/2022, LPA obtained documents to include six resident’s physician reports, six resident’s needs and services plan, facility admission agreement, and email exchanges.

On 12/29/2021, LPA interviewed Licensee at the facility. On 12/21/2021, an incident between two residents (R1 and R2) occurred which resulted in resident (R2) being transported to the hospital. After that incident, staff had requested for the family of R1 to be taken home for R1 to settle down. Licensee admits telling the family via email that he refused to take R1 back to the facility. On 12/25/2021, R1 was taken back to the facility after developing a plan of action between the facility and San Andreas Regional Center (SARC) to implement with R1 and staff. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 26-AS-20211222155702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: TREBOL HOME INC.
FACILITY NUMBER: 435202513
VISIT DATE: 06/02/2022
NARRATIVE
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Since 01/06/2022, R1 has not been residing at the facility and has moved with family.

On 01/27/2022, R1’s family received notification of a 30-day eviction notice. On 01/28/2022, the Department received notification of a 30-day eviction notice for R1. The eviction notice was incomplete and pending additional documentation for the Department to review.

On 02/02/2022, during a meeting with SARC, R1’s family, and facility staff, Licensee refused to take R1 back for the second time due to the safety concerns for other resident’s in care and facility staff.

Based on record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency is being cited. See LIC 9099-D.

An exit interview was conducted, and Plan of Correction was developed and reviewed with the with Administrator in training, Tammy Lu. A copy of this report and appeal rights were provided to the Administrator in training.

Page 2 of 2.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 26-AS-20211222155702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TREBOL HOME INC.
FACILITY NUMBER: 435202513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
CCR
85072(b)(14)
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(b) The licensee shall insure that each client is accorded the following personal rights. (12) To move from the facility in accordance with the terms of the Admission Agreement.
This requirement was not met as evidenced by:
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Licensee will review section 85072 and send a statement of understanding to LPA via email by POC due date.
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Based on record review and interview, the Licensee refused to take the resident back on multiple occassions which poses an immediate health, safety, and personal rights risk to persons 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.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3