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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 06/21/2022
Date Signed: 06/22/2022 09:03:03 AM

Document Has Been Signed on 06/22/2022 09:03 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: DATE:
06/21/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kien Linh and Tammy LuTIME COMPLETED:
11:00 AM
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An informal conference meeting was conducted via virtual platform Zoom. Present in the meeting were Licensing Program Manager (LPM) Sarah Yip and Licensing Program Analyst (LPA) Christine Dolores. Facility representatives were Administrator, Kien Linh and Administrator in training, Tammy Lu.

During the meeting, LPM Yip discussed the informal meeting process as a course of action for the facility to achieve compliance with Title 22 Regulations. The administrative action process was also discussed by LPM.

This informal meeting was initiated due to recent deficiencies cited on substantiated complaints. On June 02, 2022 the facility was cited for the following: Section 85072(b)(14) Personal Rights refusing to take a resident back on multiple occasions, Section 85068.1(c)(2) Admission Procedures not developing a needs and services plan prior to admission, Section 85102(b)(7) Emergency Intervention Prohibitions using manual restraint on a resident, Section 85122(e)(6) using manual restraint on a resident for longer than the lime limitation, Section 85161(b) not reporting the manual restraint to the Department, Section 85165(b)(1) not training staff on emergency intervention, and Section 80072(c)(7) locking a resident in a room without staff supervision.

A discussion regarding the facility's corrective plan of action was conducted today to ensure facility's compliance with regulations. The Adult and Senior Care Program recommended, and the licensee agreed to submit the following course of actions to CCLD by August 05, 2022:

See LIC809-C.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/21/2022
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1. Licensee shall develop a plan in writing describing the facility plan in properly assessing new clients and developing the Appraisal Needs and Services plan to ensure clients’ needs will be met prior to acceptance.

2. Licensee shall develop a written plan describing the staff training to ensure staff adhere to clients’ behavioral and intervention plans to meet clients’ needs.

3. Licensee shall develop a written plan describing the staff training on ensuring clients’ personal rights are not violated.

4. Licensee shall develop a written plan as an addendum to the plan of operation describing how facility shall comply with the prohibited use of manual restraint on clients in care. This shall include staff training on emergency intervention.

5. Licensee shall develop a written plan describing the facility plan in reporting incidents, be it unusual incident or communicable disease, timely to the department.

A two-year monitoring shall be put in place to ensure facility's adherence to this recommended plan and Title 22 regulations.

Licensee was made aware of resources made available by the Department to licensees such as the Technical Support Program and the website www.ccld.ca.gov.

This report was reviewed with Administrator, Kien Linh and Administrator in training Tammy Lu and a copy of the report was emailed for signature. Administrator will sign the report and email the report back to LPA.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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