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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002711
Report Date: 11/04/2024
Date Signed: 11/04/2024 10:45:54 AM

Document Has Been Signed on 11/04/2024 10:45 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TRINITY CARE HOMEFACILITY NUMBER:
347002711
ADMINISTRATOR/
DIRECTOR:		ENRIQUEZ, HELENFACILITY TYPE:
740
ADDRESS:9513 WADENA WAYTELEPHONE:
(916) 683-9096
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
11/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Helen EnriquezTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Helen Enriquez and explained the purpose of the visit.

LPA Moleski closed a complaint investigation at this facility today. During the course of this investigation, LPA Moleski discovered deficiencies unrelated to the allegation made in the complaint report.

LPA Moleski was previously informed by Enriquez that R1 had suffered a fracture to their right upper arm around the date of Friday, July 19, 2024. Enriquez had no documentation available regarding this injury, such as an incident report or other medical documentation, and no additional documentation regarding this resident. These deficiencies were previously addressed during a case management visit on 8/12/24.

Enriquez said that R1 was sent to the emergency room on July 19, 2024 and returned on that same date with a sling provided by the hospital. Enriquez said that a physician had requested an outpatient orthopedic consultation visit for R1 to be held on the following Monday, July 22, 2024. Enriquez said that she was not able to take R1 to the hospital for this visit because she would be out of the area on that date. Enriquez said she asked the doctor to reschedule, but was told that R1 needed to be seen immediately. Enriquez said she told R1’s case manager she would be able to take R1 to the hospital, but not immediately. Enriquez said that R1’s case manager felt R1’s needs were not being met, to which Enriquez said R1 could be moved out. R1 was moved out by their case worker shortly afterward, on or around July 26, according to Enriquez.

Enriquez said that one of her staff members has their driver’s license, but she would have to pay for a relief caregiver while they were transporting R1. Enriquez said that she was not compensated for transportation to R1’s medical appointments. [continued 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TRINITY CARE HOME
FACILITY NUMBER: 347002711
VISIT DATE: 11/04/2024
NARRATIVE
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22 CCR Section 87465(a)(2) states that licensees “shall provide assistance in meeting necessary medical … needs … [which] includes transportation” to medical facilities able to meet residents’ needs. It further states that, “in providing transportation the licensee shall do so directly or make arrangements for this service.” 22 CCR Section 87464 describes basic services which are required in order to obtain and maintain a license. Section 87464(f)(6) states that basic services shall at a minimum include “arrangements to meet health needs, including arranging transportation, as specified in Section 87465.”

In an interview, R1’s case manager, who is also a nurse, said that R1 was never taken to the orthopedic visit while at Trinity Care Home, and did not receive the needed medical consultation until after being placed elsewhere. R1’s case manager said the visit was medically necessary, and R1 should have been seen immediately. In an interview, R1’s home health nurse said that R1 should have received this orthopedic consultation immediately.

On July 22, 2024, R1’s home health nurse visited the facility to check on R1’s condition. In an interview, R1’s home health nurse said that they found R1 with their sling off, and with a shirt pulled over their head. The home health nurse said that staff present did not know where the sling was. Then, two days later, on July 24, 2024, the nurse arrived for another visit and found R1 was again without the sling provided by the hospital, but instead was wearing a wrist brace.

In an interview, a staff member who was present during the home health visit on July 22, 2024 (S1) said that R1’s sling “went missing.” S1 said that another staff member had misplaced it, but said they later found it. Another staff member present on this date (S2) confirmed that R1 was not wearing their sling. S5 said R1’s sling was washed and later left in R1’s closet. S5 did not know why the sling had not been put back on R1 afterward.

This facility is hereby cited per 22 CCR Sections 87465(a)(2) and 87464(f)(4). An exit interview was held with Enriquez. Appeal rights and a copy of this report was left with Enriquez.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
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Document Has Been Signed on 11/04/2024 10:45 AM - It Cannot Be Edited


Created By: Vincent Moleski On 11/04/2024 at 09:29 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 CARE HOME
FACILITY NUMBER: 347002711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2024
Section Cited
CCR
87465(a)(2)

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87465(a)(2): “(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.” This requirement was not met as evidenced by:
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Licensee agrees to submit a written plan of correction.
vincent.moleski@dss.ca.gov
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Based on interviews, transportation was not provided or arranged for R1 for a medically necessary appointment, which poses an immediate health and safety risk.
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Type A
11/05/2024
Section Cited
CCR87464(f)(4)

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87464(f)(4): “(f) Basic services shall at a minimum include: … (4) Personal assistance and care as needed by the resident … as specified in Section 87608, Postural Supports.” This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training and shall provide LPA Moleski with a sign in sheet of staff members in attendance. vincent.moleski@dss.ca.gov
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Based on interviews, R1 was not provided assistance with a medically necessary postural support on at least one occasion, which poses an immediate health and safety risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


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