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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002935
Report Date: 02/04/2025
Date Signed: 02/04/2025 12:03:35 PM

Document Has Been Signed on 02/04/2025 12:03 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TRINITY HOME FOR SENIORFACILITY NUMBER:
315002935
ADMINISTRATOR/
DIRECTOR:		CADORNA, JULIUSFACILITY TYPE:
740
ADDRESS:5405 SAGE CTTELEPHONE:
(916) 251-7689
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 6CENSUS: 3DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Oliver FuleTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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On 02/04/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year annual inspection utilizing the care tool. During today's visit LPA met with House Manager Oliver Fule, and explained the purpose of the visit.

LPA and House Manager conducted a tour of the facility. Areas toured include but not limited to, resident bedrooms, bathrooms, kitchen, garage and common areas. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven(7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen at 112 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 02/03/2025. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

LPA conducted a file review of three (3) resident files. Two (2) out of the three (3) resident files were incomplete and missing pre admission appraisals. LPA conducted a file review of one (1) staff file.

LPA requested Licensee email LPA Ratajczak current LIC500 and LIC308.

As a result of today's inspection, deficiencies observed. Please see LIC809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 2
Document Has Been Signed on 02/04/2025 12:03 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 02/04/2025 at 11:22 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TRINITY HOME FOR SENIOR
FACILITY NUMBER: 315002935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 two (2) out of three (3) residents files are incomplete with no pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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Licensee is to complete an appraisal for R1 and R2. Licensee to send completed appraisals to LPA by 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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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