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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 09/28/2022
Date Signed: 09/28/2022 04:16:08 PM

Document Has Been Signed on 09/28/2022 04:16 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:KIEN LINHFACILITY TYPE:
735
ADDRESS:3251 TREBOL LANETELEPHONE:
(408) 622-3299
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
09/28/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Tammy LuTIME COMPLETED:
04:20 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai conducted an unannounced Case Management inspection. LPA met with Administrator in training, Tammy Lu and caregiver, Loreta Bagarino .

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. During the informal meeting, licensee agreed to do the following in order to bring the facility into compliance:

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.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: TREBOL HOME INC.
FACILITY NUMBER: 435202513
VISIT DATE: 09/28/2022
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During visit, LPAs toured the facility to include the bedrooms, bathrooms, living room, kitchen, garage, and backyard. All fire exit routes were free and clear of obstruction.

LPAs interviewed S1 - S2. LPAs reviewed the facility's training records. On 06/24/2022, a total of 6 staff completed training on emergency intervention to include prohibiting the use of manual restraint. On 06/30/2022, a total of 6 staff completed training on HCBS final rule requirements which includes personal rights. On 07/07/2022, a total of 6 staff completed training on special incident reporting. On 09/01/2022, a total of 6 staff completed training on behavior support plans. Licensee will ensure all staff are provided training by 10/21/2022.

LPAs reviewed the facility's procedures to properly admitting new clients.

No deficiencies cited per California Code of Regulations, Title 22.

This report was reviewed with Tammy Lu and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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