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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601188
Report Date: 04/16/2025
Date Signed: 04/16/2025 03:32:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
07/15/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240715150655
FACILITY NAME:TRINITY CARE HOME 4FACILITY NUMBER:
075601188
ADMINISTRATOR:LICUP, GINA V. & LABAY, MFACILITY TYPE:
740
ADDRESS:55 SAN VICENTE COURTTELEPHONE:
(925) 719-1548
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 6DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Licensee/Administrator, Gina LicupTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff engaging in inapproriate relationship with resident
INVESTIGATION FINDINGS:
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On 4/16/2025 at 1:20PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver complaint findings for the above allegations. LPA met with Licensee/Administrator, Gina Licup and explained the purpose of the visit.

During the investigation LPA interviewed staff, residents, reviewed care plans, admissions agreements, physicians reports for R1, and reviewed documents. On the allegation “Facility staff engaging in inappropriate relationship with resident” LPA found the following :


Report Continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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 3
Control Number 15-AS-20240715150655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TRINITY CARE HOME 4
FACILITY NUMBER: 075601188
VISIT DATE: 04/16/2025
NARRATIVE
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 On 1/10/2025 While interviewing the Administrator/Licensee Gina Licup, they confirmed that they along with backup administrator Marjorie Osia were made of aware of S1 having married R1 while on an outing on 2/9/2024. Licensee states that they advised S1 and R1 to not disclose the marriage to other residents and staff. On 7/25/2024 LPA interviewed both R1 and S1. R1 disclosed that S1 asked them to marry them multiple times and that they initially said no but later changed their mind. R1 told LPA that the first time S1 asked them to marry it was after living at the facility for a few months and after they said no S1 asked again a few months later. S1 confirmed that they did ask R1 to marry them and they were initially hesitant but later agreed when they asked again. On 7/25/2024 LPA interviewed the Assistant Administrator Marjorie Osia who stated that they were aware of the relationship between R1 and S1. Licensee and Assistant Administrator found out about the marriage approximately a month after R1 and S1 were married. Assistant Administrator stated that they were going to make an abuse report but decided not to so that the Licensee/Administrator could handle the situation. Livensee/Administrator states that they never reported the relationship because R1 does not have a dementia diagnosis however Administrator also disclosed that R1 had recently been financially abused by their previous responsible party which is also why the administrator states that they did not inform R1’s responsible party/emergency contact.

LPA also obtained copies of the Employee handbook and reviewed that it instructed employees to not use their position for personal gain. On 1/10/2025 Administrator stated that they fired S1 on 10/31/2024 because of the ongoing investigation of the allegation “Facility staff engaging in inappropriate relationship with resident” on 11/31/2024 R1 left the facility. Administrator states that S1 and R1 now live together at R1’s home.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D

Exit interview conducted. Appeal Rights and a copy of this report provided

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240715150655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRINITY CARE HOME 4
FACILITY NUMBER: 075601188
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2025
Section Cited
CCR
87211(a)(D)
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(a)Each licensee shall furnish... reports...including, but not limited to, the following (D)Any incident which threatens...resident...by staff or...any resident.

This requirement was not met as evidence by:
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By POC Licensee agrees to review regulation and attend/provide additional training with thyself and staff and notify CCL.
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Based on LPA's interviews, Licensee failed to report S1 marrying R1 which posed a potential personal rights and safety risk to 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3