<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 04/15/2024
Date Signed: 04/15/2024 03:36:27 PM

Document Has Been Signed on 04/15/2024 03:36 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:TREBOL HOME INC.FACILITY NUMBER:
435202513
ADMINISTRATOR/
DIRECTOR:
TAMMY LUFACILITY TYPE:
735
ADDRESS:3251 TREBOL LANETELEPHONE:
(408) 300-1396
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Administrator (ADM) Tammy LuTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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) Simi Rai conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Administrator (ADM) Tammy Lu.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 06/21/2022. LPA Rai observed 3 staff members and 2 residents at the facilty since 4 residents were attending adult day program.

During visit, LPA toured the inside of the facility and observed the bedrooms, bathroom, living room and kitchen. All fire exit routes were free and clear of obstruction.

LPA reviewed 3 resident files, staff training files and facility file. LPA observed 3 out of 3 resident files had updated Appraisals/ Needs and Services Plan. LPA observed staff training completed for staff adhering to resident's behavioral and intervention plan, ensuring resident's personal rights are not violated, emergency intervention/ prohibited use of manual restrains on residents in care and reporting incident reports in a timely manner to the Department.

LPA Rai reviewed facility's intake process, facility's training plan on topics such as adhering to behavioral plan & resident's rights, and facility's process for complying with reporting incidents to the Department in a timely manner.

No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Tammy Lu and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1