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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600926
Report Date: 03/01/2024
Date Signed: 03/01/2024 11:37:07 AM


Document Has Been Signed on 03/01/2024 11:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:TRINITY CARE HOME #2FACILITY NUMBER:
075600926
ADMINISTRATOR:LICUP, GINA V.FACILITY TYPE:
740
ADDRESS:110 AVOCADO CT.TELEPHONE:
(925) 719-1548
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Gina LicupTIME COMPLETED:
11:46 AM
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
On 3/01/2024 starting 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPAs were greeted by Caregiver, Dwight Geonanga and LPA explained the purpose of the visit. Administrator, Gina Licup later arrived at 10:40 AM. The facility’s fire clearance was approved for all six (6) residents may be non-ambulatory. There were 2 staff and 6 residents present during inspection.

Starting at 10:50 AM, LPA toured facility with Administrator including but not limited to 6 bedrooms, 3 bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for residents and 1 bedroom is for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in 1 of 3 residents’ shared bathroom was measured at 115.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 5/5/2023. Emergency Disaster Plan was last posted on 1/3/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/11/2023.

At 10:00 PM, LPAs reviewed 5 residents records. At 10:15 PM, LPA reviewed 3 staff records.



REPORT CONTINUES ON 809C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TRINITY CARE HOME #2
FACILITY NUMBER: 075600926
VISIT DATE: 03/01/2024
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
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2023:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • Current Administrator’s Certificate



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2