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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 01/20/2023
Date Signed: 01/20/2023 03:44:51 PM

Document Has Been Signed on 01/20/2023 03:44 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:
01/20/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:TIME COMPLETED:
03:50 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) Christine Dolores conducted an unannounced Case Management inspection. LPA met with Administrator in training, 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. 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: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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 2
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: 01/20/2023
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
26
27
28
29
30
31
32
During visit, LPA toured the facility to include the bedrooms, bathrooms, living room, kitchen, and garage. All fire exit routes were free and clear of obstruction.

LPA 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. On 11/05/2022, a total of 8 staff completed training on behavior plan review.

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: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2