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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601125
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:23:54 PM

Document Has Been Signed on 10/23/2024 03:23 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TRINITY CARE HOME 3FACILITY NUMBER:
075601125
ADMINISTRATOR/
DIRECTOR:		LICUP, GINA V.FACILITY TYPE:
740
ADDRESS:744 ACORN CT.TELEPHONE:
(925) 230-8600
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Caregiver, Anastacio Andimat JrTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 10/23/2024 at 12:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Anastacio Andimat Jr and explained the purpose of the visit. The Administrator Gina Licup arrived at 1:30PM. The facility's fire clearance is approved for all residents may be non-ambulatory.

LPA toured facility with Caregiver 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 74 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 119.8 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 smoke detectors during visit. Fire extinguisher was last serviced on 10/3/2024 . Emergency Disaster Plan was posted on 10/5/2024. First aid kit was observed to be complete. Fire drill was last conducted on 9/2/2024 .

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.


No deficiencies cited during visit. Exit interview conducted with Administrator and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) -28-0517
Alona GomezTELEPHONE: 510-239-1306
DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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