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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 05:41:05 PM

Document Has Been Signed on 03/19/2025 05:41 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:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:58 PM
MET WITH:Wilma Bernal, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 03/19/2025 at 4:58 PM Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen conducted an unannounced Case Management visit. 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.

While LPAS were at the facility for another visit, LPAs observed the following:
  • At 4:31 PM, LPAs observed the refrigerator handle locked with a chain and a key lock.
  • At 4:32 PM, LPAs observed that the kitchen cabinets locked with a paddle lock and a key lock.

The following deficiencies was observed (see LIC 809D) and 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 Staff. Appeal Rights 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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Document Has Been Signed on 03/19/2025 05:41 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/19/2025 at 05:05 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: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2025
Section Cited
CCR
87468.1(a)(3)

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87468.1(a)(3)Personal Rights of Residents in All Facilities
(a) ...(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive...daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
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The licensee agrees to unlock the the cabinet, fridge, submit a waiver request with the dementia plan of operation, and submit proof to CCLD by POC date.
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Based on observation and interview, the licensee did not comply with the regulation cited above in having the kitchen cabinet and kitchen fridge locked which poses a potential health and safety risk to the residents in care.
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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.
SUPERVISOR'S 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
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