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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601359
Report Date: 03/03/2025
Date Signed: 03/03/2025 12:48:17 PM

Document Has Been Signed on 03/03/2025 12:48 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:TRI CITY CARE HOME IIFACILITY NUMBER:
015601359
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, BELEN V.FACILITY TYPE:
740
ADDRESS:3416 ISHERWOOD PLACETELEPHONE:
(510) 818-0473
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 6DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Belen Rodriguez, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 03/03/2025 at 8:50 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Belen Rodriguez, and explained the purpose of the visit. Administrator certificate is current. The facility’s fire clearance was approved for all six (6) may be non-ambulatory and one hospice.

LPA toured facility with Administrator inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. 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 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars, non skid shower pan, 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 03/25/2024. Emergency Disaster Plan was last posted on 03/21/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/05/2025.

At 9:08 AM, LPA reviewed 6 residents records. At 9:48 AM, LPA reviewed 5 staff records. At 11:47 AM, LPA reviewed 3 samples of residents' medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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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: TRI CITY CARE HOME II
FACILITY NUMBER: 015601359
VISIT DATE: 03/03/2025
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/10/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:30 AM, LPA observed during record review that R2 to R5's file was incomplete.

At 10:30 AM, LPA observed during record review that S4 and S5's files was incomplete.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2025 12:48 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/03/2025 at 12:21 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 II
FACILITY NUMBER: 015601359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having an incomplete file for S4 and S5 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator agrees to obtain the documents for the staffs' file and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having an incomplete file for R2 to R6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator agrees to obtain all the documents for the residents' and send 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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
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