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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 06/08/2023
Date Signed: 06/08/2023 05:26:13 PM

Document Has Been Signed on 06/08/2023 05:26 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:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Tammy LuTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Manuel Monter and Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Tammy Lu.

LPAs toured the facility inside and out. LPAs toured the facility in the following area: resident/staff bedrooms, kitchen, hallway free from obstructions, living and dining area. Food supplies were also inspected for both 7 days non-perishable and 2 days perishables. Facility first aid kit was observed and met the requirement. Toxic materials and sharp or hazardous objects were observed inaccessible to residents in care.The facility had toiletries and paper supplies. There are two bathrooms/shower with grab bars and skid mats/shower chair. The facility hot water temperatures in the kitchen was measured at 106 degrees F. The bathroom water temperature was measured ranged from 106 degrees F and 107 degrees F.

The facility fire extinguisher was also inspected. LPAs observed the date for the fire extinguisher as 9/22/2020. During inspection of the facility laundry area, LPAs observed chemicals, insecticide and a hand saw in the shelves. LPAs asked ADM if the residents have access to the garage. ADM stated, "yes they have access." During inspection, LPAs observed resident R1 in the garage door talking to S1 which was unlocked at the time. LPAs informed ADM about the observed toxins and hand saw which were not secured in the garage. ADM proceed to lock the garage door. LPAs then observed R2 take a hamper filled with clothes to the garage after S3 unlocked the garage door.

Facility smoke detectors including carbon monoxides were observed, tested and found to be functioning. The facility yard was inspected and no tripping hazards or hazardous items observed during inspection. While inspecting the back yard, LPAs observed the fence was leaning towards the Vista Verde Street. LPAs inspected the emergency exit located in the backyard and observed the door opened with physical effort. LPAs attempted to open door but the bottom portion of the door is adjusted right on the concrete causing it to drag, making it difficult to open. Page 1 out of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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 6
Document Has Been Signed on 06/08/2023 05:26 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/08/2023 at 03:20 PM
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: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the backyard fence is leaning towards the Vista Verde Drive and is not in good repair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Administrator Tammy Lu will repair the fence and submit a written plan on the timeline of when the fence will be repaired and ensure the safety of the residents while repairs occur by POC date. Once the fence is repaired, Administrator will submit a picture of the fence.
Type A
Section Cited
CCR
80023(b)(2)
Disaster & Mass Casualty Plan
(b) The plan shall be subject to review by the licensing agency and shall include: (2) Contingency plans for action during fires, floods, and earthquakes, including but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher was last inspected on 09/22/2020 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Administrator Tammy Lu will either replace or obtain inspection of current fire extinguisher by POC date. Administrator will submit a written plan to ensure the facility fire extinguisher is serviced at least annually and functioning properly in the event of a fire emergency by POC date.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/08/2023 05:26 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/08/2023 at 03:21 PM
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: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 8 employee records missing soc 341A, statement acknowledging requirement to report suspected abuse and employee rights. 1 out of 8 missing criminal record statment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Administrator was able to give LPA a copy of signed documents except for 1 employee record of employee rights due to staff was not working the day of inspection. Administrator will submit a copy of a signed employee rights for S4 by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/08/2023 05:26 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/08/2023 at 03:32 PM
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: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
80087(g)(1) storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited. LPA's observed cleaning products, insecticides on open shelf in garage. Hand saw obseved in unlocked drawer located in garage. ADM stated that residents do have access to garage, S1 stated residents help with laundry which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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During inpection, LPAs observed S1 removed cleaning products, insecticides and hand saw from the shelf and drawer and placed it in a locked cabinet under the sink located in the garage. Administrator will submit a written plan on understanding the regulation, providing training staff on ensuring the storage area is locked, and submit training log by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 06/08/2023
NARRATIVE
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LPAs reviewed facility records for staff. 2 out of 8 staff records was missing SOC 341A, statement acknowledging requirement to report suspected abuse. 2 out of 8 records was missing employee rights. 1 out of 8 records missing criminal record statement. LPAs also reviewed 5 out of 5 resident records. LPA reviewed resident R1-R5 medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1-S3) and five residents (R1-R5). LPAs also inspected 5 Out 5 residents P and I.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. Technical Violation was issued.

This report was reviewed with Administrator Tammy Lu. A copy of this report was provided during exit interview. Appeal Rights was provided.

Page 2 out of 2

End of report.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6