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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002711
Report Date: 10/24/2022
Date Signed: 10/24/2022 01:20:08 PM

Document Has Been Signed on 10/24/2022 01:20 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TRINITY CARE HOMEFACILITY NUMBER:
347002711
ADMINISTRATOR:ENRIQUEZ, HELENFACILITY TYPE:
740
ADDRESS:9513 WADENA WAYTELEPHONE:
(916) 683-9096
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 6DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Helen Enriquez - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection Visit. LPA met with Licensee/Administrator and explained the purpose of the visit. Administrator holds certificate that expires on .

This facility is a single story building licensed to serve six (5) non-ambulatory residents. LPA and administrator toured the physical plant including but not limited to resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 108.6F degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers were inspected on 2/2/2022, and smoke detectors are current and in compliance with fire safety.

LPA observed centrally stored medications was kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed one (1) resident and one (1) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

No deficiencies cited today from the CA Code of Regulations, Title 22, Division 12.

Exit interview with administrator and copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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