Trinity Care Home

Type of visit: Required - 1 Year

On 12/5/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility to conduct the annual inspection visit. LPA initially met with staff on duty, Janette Cuntapay, and stated the purpose of the visit. The Licensee/Administrator, Helen Enriquez (AD), arrived shortly after. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, 6 of which may be non-ambulatory. Facility does manage residents’ cash resources. Facility is not cleared for bedridden, delayed egress, and locked interior/exterior. Facility is approved for up to 2 hospice residents. Initial Observation: Present upon arrival were 3 staff on duty with 5 residents. LPA observed required posters and facility license. Room temperature was at 74 degrees Fahrenheit upon arrival. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 6 of 6 resident bedrooms and 2 bathrooms. The hot water temperature was measured at 116 degrees Fahrenheit. In one resident bathroom, LPA observed Lysol sprays and other solutions were in unlocked cabinet, accessible to residents, including personal hygiene supplies. LPA also observed the grab bars in the shower were loose. Also in another bathroom, labeled EMPLOYEE, LPA observed a medicated cream (M1) inside the medication cabinet. Per review of 3 residents’ Physician’s Reports, at least 2 residents were assessed to be at risk if they have access to these items. {1 of 2} Fire extinguisher was observed and was purchased on 7/18/2025. Smoke and carbon monoxide detectors were observed throughout. LPA observed centrally stored medications and sharp objects were kept locked and inaccessible to residents in care. In the kitchen area, LPA observed at least seven-day non-perishable and two-day perishable food supplies. Kitchen refrigerator and freezer temperature were unknown. Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Fence and gate were in good repair. Record Reviews: Review of 3 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Medication reviews were conducted for 2 residents. Issues were discussed with AD. LPA reviewed Infection Control Plan and Emergency Disaster Plan. Issues were discussed with AD. Based on today's visit, this annual inspection will need a CONTINUATION. The Department will return at a later date to continue the inspection. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with staff member Elaine Enriquez and explained the purpose of the visit. LPA Moleski reviewed five resident files (R1-R5) and two staff files (S1-S2). S2's most recent first aid/CPR certification expired as of November 3, 2024. S2 said that they were not aware it was expired. LPA Moleski observed that R3's pre-admission appraisal was blank. LPA Moleski spoke with licensee Helen Enriquez over the phone and asked if R3 had a pre-admission appraisal. Helen Enriquez said that she never saw R3 before they were admitted. LPA Moleski toured the facility with staff and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 112 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed a locked cabinet in the kitchen for the storage of cleaning solutions and knives. LPAs Moleski and Williams interviewed one staff member (S2) and two residents (R4-R5). This facility is hereby cited per 22 CCR Sections 87411(c)(1) and 87457(c). An exit interview was held with Elaine Enriquez. Appeal rights and a copy of this report were left with Elaine Enriquez.the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Resident suffered a fracture due to staff neglect

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Helen Enriquez and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski interviewed Enriquez, five staff members (S1-S5), five residents (R1-R5), a case worker assigned to R1, and a home health nurse assigned to R1. LPA Moleski was informed by Enriquez that R1 had suffered a fracture to their right upper arm around the date of 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. [continued on 9099-C] Unsubstantiated LPA Moleski received an incident report regarding R1’s injury on 8/12/24. The incident report stated that Enriquez was notified by a caregiver on 7/19/24 that R1 was complaining of right arm pain. R1 was taken to a hospital for treatment on that same date, according to the incident report. In an interview, Enriquez said that R1 did not fall, and did not suffer any other unusual injuries leading up to the discovery of the injury. She said her caregivers were made aware of the injury as described in the incident report when R1 started crying out when moving their arm in the shower. Enriquez said that R1 suffers from severe aphasia and is unable to articulate themselves well. However, she said that she asked the resident if they fell, to which they responded in the negative. LPA Moleski interviewed R1 at a skilled nursing facility. R1 was not able to speak clearly or elaborate upon their answers. However, when asked, R1 indicated that they had not fallen, and had not been abused or otherwise injured by staff while residing at this facility. When asked, R1 indicated that they did not know how they suffered the fracture. In interviews with all other residents of this facility (R2-R5), none indicated that they had observed any falls suffered by R1, and none had any pertinent information to share regarding the cause of R1’s injury. In interviews, no staff members (S1-S5) were able to provide pertinent information regarding the cause or circumstances surrounding R1’s injury. None of the staff interviewed had witnessed any falls immediately prior to the discovery of R1’s injury, and none of them had observed any physical abuse being perpetrated by other staff members. S1 said that R1 had never fallen, but said that they had observed R1 sleeping on their arm, potentially causing strain. S1 said they discovered the injury when R1 started repeating the word “hurt” while showering. S1 said that the administrator was called and R1 was sent to the hospital afterward. In an interview, R1’s home health nurse said that they suspected some sort of physical trauma had occurred in order to cause the injury, but had not observed any physical abuse being perpetrated by staff of this facility, and was not aware of any falls suffered by R1 while living at this facility. [continued 9099-C] In an interview, R1’s case manager said that medical documentation on file showed that R1’s injury was initially classified as pathological, but it was later determined by medical personnel that the injury was suspicious. The department has determined the following as it relates to the allegation that a resident suffered a fracture due to staff neglect: Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Enriquez.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 27-AS-20240806224550

Type of visit: Case Management - Deficiencies

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] 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.the state’s words, verbatim · CDSS document, Nov 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Nov 5, 2024

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: Based on interviews, transportation was not provided or arranged for R1 for a medically necessary appointment, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Nov 4, 2024

Plan of correction: Licensee agrees to submit a written plan of correction. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87464(f)(4) · Plan of correction due date: Nov 5, 2024

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: 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.the state’s words, verbatim · CDSS document, Nov 4, 2024

Plan of correction: 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

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation, and observed unrelated deficiencies. LPAs Moleski and Williams met with facility administrator Helen Enriquez and explained the purpose of the visit. LPAs Moleski and Williams were informed by Enriquez that a resident (R1) during the month of July 2024 ripped out their catheter and lacerated themselves in doing so. The resident was taken to the hospital, according to Enriquez. Enriquez also said that R1 was taken to the hospital on July 19, 2024, and was diagnosed with a fracture to their upper arm. The Community Care Licensing Division (CCLD) did not receive any reports regarding these incidents. Enriquez confirmed that no incident reports were sent to CCLD. In an interview, a staff member (S1) confirmed that R1 had been taken to the hospital for their catheter, and for pain in their arm. LPA Moleski asked for R1's file. LPA Moleski was told by Enriquez and S1 that R1's file was not present. According to Enriquez and S1, S1 had mistakenly placed R1's file with their belongings when moving out in late July. The whereabouts of the file were unknown to Enriquez and S1. This facility is being cited per 22 CCR Sections 87211(a)(1)(B) and 87506(e). An exit interview was held with Enriquez. Appeal rights and a copy of this report were left with Enriquez.the state’s words, verbatim · CDSS document, Aug 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Aug 26, 2024

"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision." This requirement was not met as evidenced by: Based on interviews, the licensee did not submit required incident reports after R1 suffered a genital laceration due to a catheter being removed, nor when R1 was sent to the hospital for a fracture of their arm, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Licensee agrees to send in incident reports for these incidents by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(e) · Plan of correction due date: Aug 26, 2024

"(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident." This requirement was not met as evidenced by: Based on interviews, this facility did not retain R1's file after termination of service, which poses an potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Licensee agrees to conduct a staff training regarding record retension, and will provide LPA Moleski with a sign-in sheet for the training by POC due date. vincent.moleski@dss.ca.gov