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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 04/25/2023
Date Signed: 04/25/2023 05:06:52 PM

Document Has Been Signed on 04/25/2023 05:06 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
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:
04/25/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Tammy LuTIME COMPLETED:
11:41 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management inspection 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 a meeting held on 06/21/2022. During the 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: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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: 04/25/2023
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During visit, LPA toured the facility to include the 3 resident bedrooms, 1 staff live-in room, 2 bathrooms, living room, kitchen, garage and backyard. All fire exit routes were free and clear of obstruction.

LPA interviewed ADM, 2 staff (S1, S2). LPA observed 1 client in the facility, another 4 clients went to day program.

LPA reviewed staff training records and client Appraisal Need and Service Plans.
LPA observed 5 residents' Admission Agreements.

LPA observed the client Appraisal Needs and Service Plans for the 5 current clients.

LPA observed the staff training records:
1."Crises Prevention/De-escalation" training records for 8 staff dated on 3/31/2023.
2, "The Lanterns Act, Annual Review of Rights & Privacy Practices" for 7 staff dated 3/15/2023.
3. "Medication Training" for 4 staff dated on 1205/2022.
4. "Behavior Support Plan" for 6 staff dated 9/1/2022.
5. "Emergency Intervention" for 6 staff dated 6/24/2022.
7. "Final Rules Training" for 6 staff dated 6/30/2022.
8. "Special Incident Reporting Training" for 6 staff dated 7/7/2022.

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

ADM stated the facility will keep provide the training for the staff to provide better care to the clients.

No deficiencies cited for today's inspection. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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