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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 01/12/2022
Date Signed: 01/13/2022 10:29:13 AM

Document Has Been Signed on 01/13/2022 10:29 AM - 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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:
01/12/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Andy LinhTIME COMPLETED:
12:08 PM
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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility a approximately 10:30am to open a complaint investigation. Upon arrival at the facility, LPA confirmed with staff on-site that the facility had a COVID positive resident.

LPA called the facility administrator Kien Linh (Admin) to collect more information on COVID positives at the facility. Admin confirmed that 3 staff (including himself) and 1 resident were COVID positive at the facility. Admin stated that the facility had it's first case of COVID positivity on 01/05/2022.

LPA asked Admin whether or not the COVID positives were reported to licensing, Admin stated that when sending out the mass email to SARC and resident family members, that he forgot to CC licensing on the email. An unusual incident report was not submitted within 24 hours of first confirmed positive.

Deficiency cited. See 809-D for details. Admin was not present at the facility to sign the report. During phone conversation, LPA confirmed with Admin that staff member Andy Linh was permitted to sign the report in the Administrators stead. Report was reviewed with staff member Andy Linh and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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 01/13/2022 10:29 AM - It Cannot Be Edited


Created By: Ryker Heberle On 01/12/2022 at 11:46 AM
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
, 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: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2022
Section Cited
CCR
80061(b)(1)(H)

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80061 - Reporting Requirements - Upon the occurrence... of the events specified... a report shall be made to the licensing agency within the agency's next working day during its normal business hours... (H) Epidemic outbreaks. This requirement was not met as evidenced by:
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Administrator to review reporting guidelines in Title 22 and provide proof of correction by POC due date
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Based on observation, the licensee did not comply with the section cited above by not reporting COVID positive resident and staff members to licensing, which posed a potential health, safety or 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022


LIC809 (FAS) - (06/04)
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