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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202513
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:29:52 PM

Document Has Been Signed on 09/22/2023 04:29 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:
09/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tammy LuTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Tammy Lu. The purpose of the visit to conduct a Non-Compliance Plan Quarterly Visit.
LPA Marrufo reviewed records for residents R1-R5. Each resident had Unusual Incident Reports that were reported to licensing within 7 days of the incident. Each Resident has completed Pre-Admission Appraisals. Each resident had completed Appraisal/Needs and Services Plans, except for R1, whose Appraisal/Needs and Services Plan had a blank Mental Health section. Adminstrator Tammy Lu stated she will update the section at the next care team meeting.

LPA Marrufo obtained copies of staff training records from June and July 2023. The staff training logs were for training staff on the topics of ensuring staff adhere to clients’ behavioral and intervention plans to meet clients’ needs, ensuring clients’ personal rights are not violated, and how facility shall comply with the prohibited use of manual restraint on clients in care.

LPA Marrufo interviewed staff S1-S3 on the topics covered in the staff training records during visit. LPA Marrufo conducted a tour of the facility and a wellness check of the residents during visit.

During visit, LPA Marrufo also had a discussion with Administrator Tammy Lu and staff regarding an incident reported to the Department on 06/17/2023 in which R2's family member made a medication error while the resident was visiting the family member. LPA, Administrator, and staff discussed the best practices when dealing with medication errors caused by families during visits, including recording the errors in medication logs. LPA Marrufo reviewed the medication log during visit.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Tammy Lu and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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