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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601188
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:05:21 PM

Document Has Been Signed on 10/18/2024 02:05 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 4FACILITY NUMBER:
075601188
ADMINISTRATOR/
DIRECTOR:
LICUP, GINA V. & LABAY, MFACILITY TYPE:
740
ADDRESS:55 SAN VICENTE COURTTELEPHONE:
(925) 719-1548
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Backup Administrator, Marjorie OsiaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 10/18/2024 at 10:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Backup Administrator, Marjorie Osia and explained the purpose of the visit. Administrator was out of town during inspection. The facility’s fire clearance was approved for all non-ambulatory of which one may be bedridden.

LPA toured facility with Marjorie including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. 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 107.2 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 12/07/2023. Emergency Disaster Plan was last posted on 9/20/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 9/20/2024.

At 10:40am, LPA reviewed 6 of 6 residents records. At 11:15 am, LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) -28-0517
Alona GomezTELEPHONE: 510-239-1306
DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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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