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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603643
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:43:04 PM

Document Has Been Signed on 04/18/2024 03:43 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TRINITY HILLS ESTATES - WALNUTFACILITY NUMBER:
198603643
ADMINISTRATOR/
DIRECTOR:		YU, KENNYFACILITY TYPE:
740
ADDRESS:617 WALNUT AVETELEPHONE:
(626) 235-2988
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 6DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Kenny Yu, administrator
Staff#2, manager		TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Kenny Yu, administrator, who assisted with visit. The facility is licensed to serve four (4) non-ambulatory and two (2) bedridden, ages 60 years old and above. The facility has an approved Hospice Waiver for six (6) residents. Currently, there are two (2) resident on hospice in placement. Administrator certificate is current and the expiration date is 11/30/24.

During the visit, LPA completed the Care tool, interviewed staff/residents, reviewed staff/residents' records, toured the facility, reviewed food supply and medications. The facility is a single-family residence located in a neighborhood, consists of six (6) bedrooms, five (5) bathrooms, kitchen, dining room, laundry room, family room, administrator office, activities room, detached garage, and living room with a TV. Passageways, walkways, entrance and patio were free from obstructions. Rooms were furnished with appropriate furniture for residents’ comfort and in compliance. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. The outdoor activity area had a shaded patio with ample seating.



Hot water temperature was measured in a range of 110.2 - 115.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. Sufficient supply of perishable and nonperishable foods was observed. Knives, tools, sharp items were inaccessible to residents. Smoke and carbon monoxide detectors were dual/hardwired and operable. Fire extinguishers were fully charged. Mandated documents and signages were posted in common areas. Medication was centrally stored in a locked cabinet. Resident records were stored in a locked cabinet.

Deficiencies were observed and cited per California Code of Regulations, Title 22, in LIC 809D. An exit interview was conducted and this report/appeal rights were provided to staff#2.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 04/18/2024 03:43 PM - It Cannot Be Edited


Created By: Bonnie Tao On 04/18/2024 at 03:03 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TRINITY HILLS ESTATES - WALNUT
FACILITY NUMBER: 198603643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
Incidental Medical and Dental Care 87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained.
This requirement is not met as evidenced by:
Resident#1's medication (bubble packs) and medication log were not matched. Medication (Rx) of Furosemide 20 mg had 4 days discrepancy with Rx's log; Lorazepam 0.5mg AM and PM had 2 days discrepancy with Rx's log; Metoclopramide 10 mg had 3 days discrepancy with Rx's log. Licensee did not have explanation regarding the discrepancy between R1’s medication and Rx log. Licensee was unsure R1's medication log or start date was updated as Rx was administered.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee agreed to provide (1) additional medication administration assistance training to all staff and provide proof to the department; (2) review Title 22, Section 87465(h) and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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