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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601359
Report Date: 03/19/2025
Date Signed: 03/19/2025 05:39:47 PM

Document Has Been Signed on 03/19/2025 05:39 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: 5DATE:
03/19/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:25 PM
MET WITH:Wilma Bernal, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
04:58 PM
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On 03/19/2025 at 4:25 PM Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen conducted an unannounced Case Management Plan of Correction visit regarding deficiencies that was observed during annual visit on 03/03/2025. LPAs met with Care Staff, Wilma Bernal, and explained the purpose of the visit. Administrator gave authorization on the phone for staff to sign the report.

On a previous visit, LPA cited a deficiency on Resident Records, CCR 97506(b) which had a Plan of Correction (POC) due date of 03/17/2025. The facility did not send proof of the plan of correction.

During the visit, LPAs reviewed resident's record and observed that it is complete.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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