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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603643
Report Date: 03/18/2025
Date Signed: 03/24/2025 02:57:10 PM

Document Has Been Signed on 03/24/2025 02:57 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TRINITY HILLS ESTATES - WALNUTFACILITY NUMBER:
198603643
ADMINISTRATOR/
DIRECTOR:		SANDOVAL, JENNIFERFACILITY TYPE:
740
ADDRESS:617 WALNUT AVETELEPHONE:
(626) 235-2988
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 6DATE:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:21 AM
MET WITH:Jennifer Sandoval - Administrator TIME VISIT/
INSPECTION COMPLETED:
04:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Winnie Poon, Activity Director for the facility, and explained the purpose of the visit. Administrator Jennifer arrived shortly thereafter. There are six (6) residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices were observed.


· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, two (2) of which may be bedridden, and a hospice waiver approved for six (6) residents. The facility consists of a kitchen, a dining room, two (2) living rooms, one (1) staff bedroom, five (5) resident bedrooms, a staff office, four (4) bathrooms which all measured within the required range of 105 – 120 Degrees Fahrenheit, along with a backyard that contains a shaded area. The backyard area has an accessory dwelling unit (ADU) that contains an additional two (2) bedrooms for residents, a bathroom whose hot water temperature was 117.1 Degrees Fahrenheit, and a kitchen. The facility was observed to be in good repair.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguishers in the facility.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 03/24/2025 02:57 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 03/18/2025 at 02:54 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: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff members, because Staff #2 is not currently associated to the facility and it is not known if Staff #2 has a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee will associate the staff in question to the facility via Guardian and provide a copy of the association list as proof. This will be emailed to LPA by the POC due 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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/24/2025 02:57 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 03/18/2025 at 02:54 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: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff members, because Staff #2 does not have the records required in section 87412, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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Licensee/Administrator is to ensure that all staff members have all records required as part of Title 22 section 87412 at all times. Licensee/Administrator is to gather all required documents and submit them to LPA by the POC due date.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 6 staff members, because Staff #3 has an expired First-Aid/CPR certificate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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Administrator is to ensure that all staff that assist clients with their ADLs have an active first-aid/cpr certificate at all times. Staff #3 is to renew their certificate and email the updated certificate to LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TRINITY HILLS ESTATES - WALNUT
FACILITY NUMBER: 198603643
VISIT DATE: 03/18/2025
NARRATIVE
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Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, two (2) of which may be bedridden, and a hospice waiver approved for six (6) residents.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Nineteen (19) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Six (6) staff files were reviewed for criminal background clearance and training.


· One (1) staff member did not have a criminal background clearance on file and was not associated to the facility.
· Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR trainings that are active.
· One (1) staff member has a First-Aid/CPR certificate that expired in October of 2024.
· The administrator’s certificate expires on 7/22/2025.

Resident Rights/Information:

· Physician orders were reviewed for six (6) resident files.

· Medications were also reviewed for six (6) residents.

Resident Records/Incident Reports:

· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TRINITY HILLS ESTATES - WALNUT
FACILITY NUMBER: 198603643
VISIT DATE: 03/18/2025
NARRATIVE
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 Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan (LIC610E) was found in the facility.

· The last emergency and disaster drill was conducted on 2/10/2025.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· All six (6) residents are receiving hospice services.

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/24/2025 02:57 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 03/18/2025 at 03:42 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: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff members, because Staff #2 did not have any files required in Section 87412, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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Licensee/Administrator is to ensure that all staff members have all records required as part of Title 22 section 87412 at all times. Licensee/Administrator is to gather all required docuemtns and submit them to LPA by the POC due 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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/24/2025 02:57 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 03/18/2025 at 03:48 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: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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