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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 12:56:30 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
01/04/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220104103151
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:
12:15 PM
ALLEGATION(S):
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Staff are not trained to meet resident's needs
Staff is keeping resident locked in the room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegation and met with Administrator in training, Tammy Lu.

The following documents were obtained during the complaint investigation to include R1’s needs and services plan, R1’s prescription letters, R1’s behavior support plan, facility emergency intervention plan, all staff training from 2021 to February 2022, visitation log from 12/2021 – 01/2022, incident reports, and external correspondences.

On 12/16/2021, R1 was restrained for a total of one hour. On 12/21/2021, R1 was restrained for a total of one and a half hours. On 12/28/2021, a Crisis Counselor noted that staff reported to restrain R1 for one to two hours until he calms down.

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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 7
Control Number 26-AS-20220104103151
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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On 01/03/2022, a Crisis Counselor noted that staff reported to sometimes place R1 in a restraint when R1 is aggressive because they worry R1 will harm others. During question, staff stated to use restraint on R1 last week and the restraint can go up to two hours at a time or until R1 calms down.

Based on interview, on 12/29/2021, the Administrator stated to be a trainer of Pro-Act and has taught some techniques to staff but has never held a formal training nor documented the staff training on Pro-Act.

Based on record review, on 06/12/2021, seven out of nine staff received training on understanding challenging behaviors. Seven out of nine staff received training on supporting individuals in a person-centered way. On 08/18/2021, seven out of nine staff received training on medication management and compliance. On 09/20/2021, nine out of nine staff were provided in-service training on items included but not limited to behavioral support plans and when to implement proactive vs reactive strategies.

The review of facility staff training records did not indicate staff were provided training nor obtained a certificate of completion of Emergency Intervention training.

Staff is keeping resident locked in the room
On 01/03/2022, R1 was observed locked in the bedroom without supervision by an outside agency. R1 was not observed to be in crisis at that moment the bedroom door was locked.

Two out of two witnesses were interviewed. Two out of two witnesses confirmed to observe the staff locked R1 in the room during their facility visit.

Three out three staff were interviewed. Three out of three staff confirmed that R1 was locked in bedroom of the facility

Based on record review, on 01/03/2022, visit notes were provided from an outside agency to R1’s responsible party regarding the observation of staff locking the client’s bedroom while the client was inside. In another instance that day, it was noted that staff locked the door again after the client went back into the room from the restroom. Staff stated R1 would be locked in the room for five to ten minutes but knows it’s unsafe, so they do not do it often.
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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: 2 of 7
Control Number 26-AS-20220104103151
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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On 01/14/2022, San Andreas Regional Center arrived at the facility unannounced and issued facility a Corrective Action Plan (CAP) regarding resident being locked in bedroom without supervision posing a danger to resident’s health and safety.

The review of facility’s Emergency Intervention Plan did not indicate an approval from the Department to use a seclusion room nor include information on the facility’s policy and procedures to use a seclusion room.

The Department has conducted an investigation of the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with Administrator in training, Tammy Lu. A copy of this report, along with the facility's appeals rights were provided.

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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 7
Control Number 26-AS-20220104103151
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
85165(b)(1)
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(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (1) Staff who use, participate in, approve or provide visual checks of manual restraints or seclusions, shall be trained in the manual restraint or seclusion technique utilized. This requirement is not met as evidenced by:
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Licensee will review section 85165 and ensure to never use manual restraint on a resident if staff have not successfully completed training on manual restraint. Licensee to provide proof/plan of staff training on emergency intervention by POC date.
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Based on interview and record review, facility staff were not provided complete training on emergency intervention to include the use of manual restraint prior to staff using manual restraint on R1 which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
06/03/2022
Section Cited
CCR
80072(a)(7)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night. This requirement is not met as evidenced by:
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Licensee will review section 80072 and ensure to never lock a resident in a room under any circumstance. Licensee will send LPA a statement of understanding by POC date.
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Based on interview and record review, facility staff locked R1 in a bedroom without staff’s supervision on several occasions 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: 4 of 7
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
01/04/2022 and conducted by Evaluator Christine Dolores
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220104103151

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:
12:15 PM
ALLEGATION(S):
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Staff are not meeting resident hygiene
Facility is refusing visitation
Facility staff is not following doctor’s order
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED REPORT FROM VISIT DATE 06/02/2022. On 07/27/2022, Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegation and met with Administrator in training, Tammy Lu.

The following documents were obtained during the complaint investigation to include R1’s needs and services plan, R1’s prescription letters, R1’s behavior support plan, facility emergency intervention plan, all staff training from 2021 to February 2022, visitation log from 12/2021 – 01/2022, incident reports, and external correspondences.

On 01/03/2022, visit notes from an outside agency was provided to R1’s responsible party noting that facility staff stated to had not showered R1 in a week due to the difficulty of potential aggressive behavior the client will exhibit.
Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
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: 5 of 7
Control Number 26-AS-20220104103151
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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Based on record review, R1’s appraisal needs and services plan dated 06/28/2018 states the resident will be clean as evidence by being odor free, skin free of redness, irritation/flakes, and hair clean and shining.

Based on interview, Licensee stated R1 was given cloth baths as an alternative to showers due to R1 refusal to fully shower with running water. Three out of three staff were interviewed. Three out of three staff states R1 was given an alternative to showers and was not left unclean.

One witness was interviewed. Based on interview, the witness did not observe resident with foul odor, makings on skin, greasy hair, or flakes/dandruff.

Facility is refusing visitation
On 12/30/2021, R1’s family was denied by the Licensee visitation and the ability to take home R1 for the weekend.

On 12/10/2021, a plan was developed by a behavior consultant on strategies for a successful transition for R1. The plan was received via email by the Licensee, family member, and other external agencies. R1’s plan stated that family involvement is always encouraged and appreciated, and the transitional period is difficult for R1 and family. The behavior consultant is appreciative of the family involvement but “fears it might be backfiring”. The plan suggested for frequent family visits to resume once R1 is fully transitioned into the facility.

On 12/28/2021, the District Manager from San Andreas Regional Center (SARC) communicated with the Licensee via email stating it was best for R1 to not go home with family for the weekend. Included in the email communication was the District Manager of SARC, Licensee, and family member.

On 12/30/2021, R1’s family was denied by the Licensee for visitation and the ability to take R1 home for the weekend based on the new agreement.

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SUPERVISORS NAME: Sarah Yip
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: 6 of 7
Control Number 26-AS-20220104103151
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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Based on interview, the Licensee stated an agreement was made with R1’s family to hold back on visitation to help R1 transition into the home. Licensee states visitation was modified by allowing the family to see R1 through the window or areas of the facility without visibly being seen by R1. This idea was suggested and verbally agreed upon during a meeting with SARC, Licensee, and family. Based on the review of the facility’s visitation log, R1’s family visited the facility multiple times throughout the month of R1’s admission.

Facility Staff is not Following Doctor’s Order
Three out of three staff were interviewed. Three out of three staff states the medical device was not a prescription but a direction from R1’s responsible party.

From 12/25/2021 – 01/03/2021, R1’s medical tracking device did not record data for six out of ten days due to the device not being charged. Three out of three staff states R1’s medical device was not being charged due to the difficulty in removing the medical device from R1.

Based on interview, the Licensee stated R1’s responsible party did not provide a prescription or doctor’s order related to R1’s medical tracking device. Facility was only provided a list of R1’s medications. Based on record review, the facility was provided a prescription letter on 07/16/2021 and 12/14/2021 listing only R1’s medications. R1’s doctor’s order prescribing the medical tracking device was dated on 01/10/2022. R1 no longer resided at the facility as of 01/06/2022. R1’s appraisal needs and services plan dated on 06/28/2018 does not indicate the use of the medical tracking device.

R1’s Medication Administration Record (MAR) was reviewed and indicated no missed medication or refusal of medication. The review of the photographed medication bubble pack lacks information. Four out of four staff states R1 did not miss a medication.

The Department has investigated the above allegations. Based on interviews and records review, the Department has determined that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

This report was reviewed with Administrator in training, Tammy Lu and a copy of this report was provided.
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SUPERVISORS NAME: Sarah Yip
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: 7 of 7