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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601188
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:45:38 PM


Document Has Been Signed on 12/14/2023 04:45 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:LICUP, GINA V. & LABAY, MFACILITY TYPE:
740
ADDRESS:55 SAN VICENTE COURTTELEPHONE:
(925) 719-1548
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 6DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator, Marjorie OsiaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 1:35PM. Upon arrival, LPA met with caregiver Edilberto Cama. Assistant Administrator, Marjorie Osia later arrived at 2:15pm, Administrator, Jessica Licup arrived at 2:20PM and Licensee Gina Licup arrived at 4:00pm.

LPA toured the facility with 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 72 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 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week nonperishable and 2-day perishable supply of food.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/07/2023. Emergency Disaster Plan was last posted on 9/10/2023. First aid kit was observed to be complete. Fire drill was last conducted on 10/15/2023.

LPA reviewed 5 staff records and 5 of 5 staff are associated and have current first aid training. LPA reviewed 5 residents record and a sample of resident's medications were reviewed.

Report continues on LIC 809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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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 4
FACILITY NUMBER: 075601188
VISIT DATE: 12/14/2023
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/31/2023:

LIC 500 Personnel Report
Updated Facility Sketch


Exit interview conducted with Licensee 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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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