Tri City Care Home

Type of visit: Required - 1 Year

On 12/5/2024 at 9:00 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and met with staff care staff, Rachiel Dime. The Administrator Belen Rodrigues was informed over the phone about the purpose of the visit. The Administrator (Administrator holds a certificate #6021647740 expiration 12/16/26 arrived at the facility at around 1PM. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room and outdoor area. The facility’s temperature was maintained at 73 degrees Fahrenheit. Bathrooms have grab bars and non-skid mats. The facility has appropriate lighting throughout. Extra linens and towels were observed in the hallway closet. Hot water temperature measured 115 degrees Fahrenheit. There were sufficient supplies of perishable and non-perishable foods. First aid kit was observed completely and updated. Fire extinguisher was last inspected on 3/05/2025. Fire Drill last conducted 10/17/25. Emergency disaster plan last updated on 10/17/25. Facility has an effective liability from 1/17/25 to 1/17/26. LPA reviewed 6 resident files and 4 staff files. All staff are fingerprint cleared and associated to the facility. All staff have current First Aid and CPR training. Report continued on LIC 809c... Deficiencies observed: At around 10:40 am, LPA observed Clorox and Lysol spray in basket near front entrance. Chemical left underneath the sink. Disinfected wipes left in bathroom. LPA observed knives on table near front door. At around 10: 50am, LPA observed multiple expired and mold food including but not limited to salad dressing, cheese, salad, bell pepper, cans good, and ect. At around 11am, LPA observed containers with food are not labeled properly. At around 11:30am, LPA observed prescribed medication including but not limited to cream, in resident rooms. At around 12pm, LPA conducted files reviewed there is no Liability insurance. Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Exit interview was conducted and Appeal Rights were provided. Administrator agrees to check all residents’ rooms and lock all medication in a lock area. Administrator agrees to conduct training for all staff and submit proof to CCLD by POC date.the state’s words, verbatim · CDSS document, Dec 16, 2025

Type of visit: Required - 1 Year

On 12/5/2024 at 9:30 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and met with staff care staff, Mathew Aviles. The Administrator was informed over the phone about the purpose of the visit. The Administrator (Administrator cert#6021647740 expiration 12/16/24) arrived at the facility at around 10:15am. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room and outdoor area. The facility’s temperature was maintained at 73 degrees Fahrenheit . Bathroom have grab bars and non-skid mat. The facility has appropriate lighting throughout. Extra linens and towels were observed in the hallway closet. Hot water temperature measured at 115.3 degrees Fahrenheit. There were sufficient supplies of perishable and non perishable foods. First aid kit was observed complete and updated. Fire extinguisher was observed that appeared full and has purchase date of 2/25/2024. Fire Drill last conducted 10/14/24. Emergency disaster plan last updated on 3/21/24. Liability insurance effective 1/17/2024 to 1/17/25. LPA reviewed 6 resident files and 3 staff files. All staff are fingerprint cleared and associated to the facility. All staff have current First Aid and CPR training. At around 10:15 am, LPA observed cheese, and tomato have mold in the refrigerator. Cleared At around 10:25am, LPA observed ant, roach, and spider (hot shot) spray inside room 4 bathroom. Cleared At around 10:40am, LPA observed residents’ medication are not in its original container. Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Exit interview was conducted and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Overcapacity

On this day at around 11:55 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding for the above allegation and met with Eva Penas. LPA explained to Penas the purpose of the visit. The Administrator was out of the facility and authorized Penas to sign the report. On 3/28/2024, LPA conducted initial 10-day visit, obtained records and interviewed the Administrator and Staff 2 (S2). On 4/2/2024, LPA reviewed records and Guardian. Based on interview conducted on 3/28/2024, the Administrator states that Witness 1 (W1) has been staying at the facility in one of the staff rooms since December 12, 2023. The Administrator states that W1 is temporarily staying at the facility because W1 has issues and that W1 will be leaving on April 11, 2024. The Administrator added that W1 is fingerprint cleared and associated to the facility. The Administrator states that W1 is paying $1,000/month for food and utilities but the facility does not provide care because W1 is independent. continuation on Lic 9099C Substantiated Based on interview conducted with S2, S2 confirmed with LPA that W1 has been staying in one of the caregiver rooms since December 2023. S2 states W1’s husband comes every day to pick up W1 and would bring back W1 at the end of the day. S2 added that if W1 would use the bathroom, S2 states W1 does not need a lot of assistance but S2 would make sure that W1 is safe due to W1’s knee surgery. S2 added that there were times that S2 would assist W1 while using the bathroom. A review of Guardian shows W1 associated to the facility on 12/12/2023 as an employee. However, the facility’s Lic 500 does not indicate that W1 is one of the employees at the facility. Despite the Administrator’s denial that W1 is a resident, the facility’s license allows the facility to admit/retain six (6) residents only. And the fact that W1 pays $1,000/month, is not listed in Lic 500 as an employee and that S2 does provide assistance to W1 on as needed basis are sufficient evidence to substantiate the allegation “Over capacity.” Based on interviews and record review conducted, the above allegation is substantiated. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is cited on the attached LIC 9099D. Civil penalty in the amount of $500.00 is assessed for today's visit. Exit interview was conducted and Appeal Rights was provided to Penas.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 15-AS-20240325163517

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Apr 9, 2024

87204(a) Limitations - Capacity and Ambulatory Status (a)(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by: The facility admitted W1 temporarily while recovering from surgery despite at full capacity which poses an immediate risk to the health and safety of clients.the state’s words, verbatim · CDSS document, Apr 9, 2024

Plan of correction: During the visit, LPA was informed by the Administrator that W1 has moved out of the facility on 3/29/2024. Civil penalty of $500 is assessed for today's visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Apr 10, 2024

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on interviews conducted, the facility failed to comply with State Fire Marshall regulations when the facility admitted W1 who was recovering from surgery and stayed in one of the caregivers' room which poses an immediate risk to the health and safety of clients under care.the state’s words, verbatim · CDSS document, Apr 9, 2024

Plan of correction: The Administrator states W1 moved out of the facility on 3/29/2024. The Administrator will submit self-certification of understanding of Sections cited and submit to CCL by POC date.

Type of visit: Case Management - Other

While at the facility delivering finding for complaint #15-AS-20240325163517, LPA observed R1 asking S2 if R1 is able to eat. S2 told R1 that R1 can go ahead and eat lunch. LPA asked S2 if R1 is diabetic. S2 states R1 is diabetic. When asked if R1 is on insulin, how often R1 needs to check blood sugar and whether R1 is able to check own blood sugar. S2 states R1 is on oral medication and needs blood sugar checked twice a day. S2 states R1 is unable to check own blood sugar. And staff checks R1's blood sugar. The facility does not have an approved exception. Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D). Exit interview was conducted with Penas and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Apr 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Apr 15, 2024

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional This requirement is not met as evidenced by: Based on interview conducted, R1 is diabetic and needs FBS check 2x a day. However, R1 is unable to check own blood sugar. Staff check R1's FBS and facility does not have an approved exception.the state’s words, verbatim · CDSS document, Apr 9, 2024

Plan of correction: By POC date, the Administrator will provide CCL plans on how to address R1's diabetes and submit to CCL.

Type of visit: Required - 1 Year

This is an amended copy of the report previously issued to the facility on 3/21/2024. This report was erroneously pulled from the incorrect facility. The amended report can be found under Tri City Care Home ll Lic #015601359. LPA Luisa Fontanilla arrived at the facility at around 1:20 pm to amend report previously issued on 3/21/2024. The Administrator was informed about the visit and she authorized staff Wilma Bernal to sign the report. A copy of this report was provided to Bernal. Exit interview was conducted and Appeal Rights was provided to Rodriguez.the state’s words, verbatim · CDSS document, Mar 21, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.