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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601125
Report Date: 01/04/2024
Date Signed: 01/04/2024 11:39:53 AM


Document Has Been Signed on 01/04/2024 11:39 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 3FACILITY NUMBER:
075601125
ADMINISTRATOR:LICUP, GINA V.FACILITY TYPE:
740
ADDRESS:744 ACORN CT.TELEPHONE:
(925) 230-8600
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Caregiver, Anastacio AndimatTIME COMPLETED:
11:50 PM
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Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Inspection on this date starting at 9:25am. Upon arrival, LPA met with Caregiver, Anastacio Andimat Jr. and Assistant Administrator, Marjorie Osia. Administrator Gina Licup arrived at 11:30am. The facility's fire clearance is approved for all residents may be non-ambulatory.

LPA toured facility with Assistant Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118.8 degrees F. 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.

LPA observed carbon monoxide and interconnected smoke detectors were observed during visit. Fire extinguisher was last serviced on 10/3/2023 . Emergency Disaster Plan was last posted on 1/02/2024 . First aid kit was observed to be complete. Fire drill was last conducted on 12/20/2023 .

LPA reviewed 3 staff records and 3 of 3 are associated. LPA reviewed 4 residents records 4 of 4 residents have appraisals of needs and services.


Report continues on LIC809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TRINITY CARE HOME 3
FACILITY NUMBER: 075601125
VISIT DATE: 01/04/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 1/19/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted with Administrator 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: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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