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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200684
Report Date: 03/04/2022
Date Signed: 03/04/2022 03:31:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210604160826
FACILITY NAME:TRINITYVILLE, INC.FACILITY NUMBER:
019200684
ADMINISTRATOR:RIOS, VIRGINIAFACILITY TYPE:
740
ADDRESS:3731 JOAN AVENUETELEPHONE:
(925) 332-5709
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Virginia Rios, Administrator
Leslie Colte, Caregiver		TIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff are not providing adequate supervision of residents
INVESTIGATION FINDINGS:
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On 03/04/22 at 3:20PM, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to deliver findings on the above allegation. LPA explained the purpose of the visit with staff (S1) and administrator who authorized S1 to act on her behalf and sign the reports.

Allegation: Staff are not providing adequate supervision of residents
Investigation Finding: UNSUBSTANTIATED
During investigation, LPA L. Fontanilla interviewed Administrator and staff on 6/7/2021. On 9/22/2021. LPA Fontanilla interviewed resident’s (R1’s) responsible person. On 9/22/2021, LPA Fontanilla reviewed R1’s needs and services plan (ANS), Physician’s Report, Personnel records (LIC 500), Resident Roster and caregiver notes.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20210604160826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TRINITYVILLE, INC.
FACILITY NUMBER: 019200684
VISIT DATE: 03/04/2022
NARRATIVE
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Based on interviews conducted, both S1 and S2 admitted that a party was held at the facility’s garage on Christmas of 2020 evening. However, S1 states that it was conducted during S1’s off hours and S2 was the person on duty. S2 confirmed with LPA that the party was conducted during S1’s off hours. And that S2 was the person on duty for the shift. S2 added that all residents were provided the needed care and that no resident fell during the shift. S2 added that R1 calling for “help” is part of R1’s behavior having been diagnosed with dementia. On 9/22/2021, LPA L. Fontanilla interviewed R1’s responsible person who stated that R1 has never fallen at the facility. LPA reviewed R1’s records and observed that R1 was diagnosed with dementia and is confused and disoriented. On 9/22/2021, LPA interviewed the Administrator who states that no resident has fallen in December 2020.

Based on interviews and record reviews conducted, the above is allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiency observed during visit. Exit interview conducted and a copy of this report provided via e-mail to administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
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