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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601207
Report Date: 12/16/2025
Date Signed: 12/16/2025 02:15:19 PM

Document Has Been Signed on 12/16/2025 02:15 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TRI CITY CARE HOMEFACILITY NUMBER:
015601207
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, BELEN V.FACILITY TYPE:
740
ADDRESS:2438 DOUGLAS STREETTELEPHONE:
(510) 324-0999
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
12/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Belen Rodrigues, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 12/5/2024 at 9:00 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and met with staff care staff, Rachiel Dime. The Administrator Belen Rodrigues was informed over the phone about the purpose of the visit. The Administrator (Administrator holds a certificate #6021647740 expiration 12/16/26 arrived at the facility at around 1PM.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room and outdoor area. The facility’s temperature was maintained at 73 degrees Fahrenheit. Bathrooms have grab bars and non-skid mats. The facility has appropriate lighting throughout. Extra linens and towels were observed in the hallway closet. Hot water temperature measured 115 degrees Fahrenheit. There were sufficient supplies of perishable and non-perishable foods. First aid kit was observed completely and updated. Fire extinguisher was last inspected on 3/05/2025. Fire Drill last conducted 10/17/25. Emergency disaster plan last updated on 10/17/25. Facility has an effective liability from 1/17/25 to 1/17/26. LPA reviewed 6 resident files and 4 staff files. All staff are fingerprint cleared and associated to the facility. All staff have current First Aid and CPR training.

Report continued on LIC 809c...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/16/2025 02:15 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 12/16/2025 at 01:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRI CITY CARE HOME
FACILITY NUMBER: 015601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having Clorox and Lysol spray in basket near front entrance. Chemical left underneath the sink. Disinfected wipes left in bathroom. LPA observed knives on table near front door. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2025
Plan of Correction
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Administrator agrees to put all disinfected and sharps in a locks area. Administrator agrees to conduct training for all staff and submit proof to CCLD by POC date.
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by having multiple expired and mold food including but not limited to salad dressing, cheese, salad, bell pepper, cans good, and ect, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2025
Plan of Correction
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 Administrator agrees toss out all food that is expired. Administrator agrees to conduct training for all staff and submit proof to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 02:15 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 12/16/2025 at 01:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRI CITY CARE HOME
FACILITY NUMBER: 015601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having prescribe medication including but not limited to cream, in resident rooms. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2025
Plan of Correction
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Administrator agrees to check all residents’ rooms and locks all medication in a lock area. Administrator agrees to conduct training for all staff and submit proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 02:15 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 12/16/2025 at 01:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRI CITY CARE HOME
FACILITY NUMBER: 015601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(2)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (2) Any items in subsection (a)(1) that are transferred from their original container to another container shall have a legible label that indicates:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by not having containers with food are not labeled properly. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Administrator agrees to label all food containers with open date and expired date. Administrator agrees to conduct training for all staff and submit proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TRI CITY CARE HOME
FACILITY NUMBER: 015601207
VISIT DATE: 12/16/2025
NARRATIVE
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Deficiencies observed:

At around 10:40 am, LPA observed Clorox and Lysol spray in basket near front entrance. Chemical left underneath the sink. Disinfected wipes left in bathroom. LPA observed knives on table near front door.

At around 10: 50am, LPA observed multiple expired and mold food including but not limited to salad dressing, cheese, salad, bell pepper, cans good, and ect.

At around 11am, LPA observed containers with food are not labeled properly.

At around 11:30am, LPA observed prescribed medication including but not limited to cream, in resident rooms.

At around 12pm, LPA conducted files reviewed there is no Liability insurance.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview was conducted and Appeal Rights were provided.

Administrator agrees to check all residents’ rooms and lock all medication in a lock area. Administrator agrees to conduct training for all staff and submit proof to CCLD by POC date.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC809 (FAS) - (06/04)
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