The Trinity

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Jethronel Lazaga, Continual Administrator's Certification expires 02/13/2027. There are currently 8 residents who reside at this home and there is 4 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 113 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed 4 staff files, and 4 resident files (including 2 hospice binders), Plan of Operation, Emergency Disaster Plan, and Infection Control Plan. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Jethronel Lazaga and copy of report left at facilitythe state’s words, verbatim · CDSS document, Mar 21, 2026

Allegation investigated: Staff use inappropriate restraints on residents.

Licensing Program Analyst (LPA) L. Xiong conducted the an unannounced complaint investigation visit to the facility. LPA met with administrator J. Lazaga during the visit. During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. The evidence from the investigation indicated that the facility staff did use inappropriate restraint on resident. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”) Substantiatedthe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 24-AS-20260122170820

From the deficiency page — Deficiency type: Type A · Section cited: CCR 97608(a)(3) · Plan of correction due date: Feb 12, 2026

87608(a)(3) Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Per Administrator, will conduct an inservice-training for staff by the poc date.

Allegation investigated: Staff did not ensure consumables provided to resident were free from contamination.

On 10/21/25, Licensing Program Analysts (LPAs) L. Salazar and S. Doucette arrived to the facility unannounced to conduct the required 10-day site inspection. LPAs were greeted by staff, stated the purpose of the visit and were allowed entry. Administrator arrived to the facility shortly after. Based on LPAs observations and interviews conducted, Resident R1's lemondade had 4 small mold spores. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter 8, is being cited on the attached LIC 9099D. If not corrected, the violation will have a potential risk to the health, safety, or personal rights of clients in care. An exit interview was conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. A copy of this report and appeal rights were discussed and provided at the time of visit. Substantiatedthe state’s words, verbatim · CDSS document, Oct 21, 2025 · control 24-AS-20251013113355

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Oct 31, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement was not met as evidenced by LPA's observation and interviews that Resident R1's lemonade, at R1's beside, to have 4 small mold spores in it. If not corrected, the violation will have a potential risk to the health, safety, or personal rights of clients in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Administrator will send proof that all staff have been made aware and agreed to change Resident R1's drinks 3 times a day.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA's) S. Doucette and L. Salazar arrived at the facility unannounced to conduct a 10 day complaint investigation. During the course of the investigation, LPA's observed deficiencies. LPA's met with Administrator Jethronel Lazaga. LPA's conducted a tour of the facility. LPA's reviewed records. Administrator stated staff do not have required annual training. LPA's observed 3 out of 3 staff present that did not have staff training. Hospice Care Plans do not reflect appropriate care to allow facility to operate within the issued license and staff are not trained to care for residents on Hospice. A copy of this report was provided with appeal rights and plans of corrections.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Nov 14, 2025

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: Licensee did not have staff training for 3 out of 3 staff that were providing care at the facility, which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee agrees to submit training for all staff and submit proof of training by POC due date 11/14/25

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633 · Plan of correction due date: Nov 14, 2025

87633 Hospice Care of Terminally Ill Residents (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. This requirement was not met as evidenced by: Licensee does not have hospice training for staff caring for 7 out of 7 hospice residents which poses a potential health safety and or personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee agrees to have Hospice provide training for staff regarding care of each resident on Hospice by POC due date 11/14/25.

Type of visit: Required - 1 Year

On March 11, 2025, Licensing Program Analyst (LPA) Rachel Bruce arrived for an unannounced required annual inspection. LPA met with Jethronel Lazaga, AD) Administrator/Licensee. AD provided tour and LPA conducted a thorough inspection and review of required documentation. Due to computer issues, LPA was unable to complete the documentation portion of the inspection using the CARE TOOLS program. Because of that, LPA had to return to issue the inspection report and close the inspection process. The time spent at the facility completing the inspection on March 11, 2025 was from 10 AM to 2:00 PM. No documentation was left at the facility on that date due to computer issues. On March 28, 2025, LPA Bruce returned to the facility to issue the inspection report completing the annual required inspection. Below is a summary of the inspection conducted on the initial visit of March 11, 2025. Resident rooms contained required furnishings and lighting. This facility has 6 resident bedrooms and 5 bathrooms. LPA observed required items in bathrooms with hot water measuring within the regulatory requirement range. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Medications are centrally stored and locked in closet near the kitchen. Cleaning supplies are stored in locked laundry room. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit is located in medication storage closet and found to contain required items. Fire Extinguishers are located throughout the facility and were serviced last on 2/20/2024. Facility has a sprinkler system. Per Licensee, Smoke and Carbon Monoxide detectors are a combo alarm and are tested annually by AAA Quality Services fire safety company, the latest inspection was conducted on 2/20/2024. The next annual appointment for testing the alarms and extinguishers is scheduled for the first week of April. LPA conducted resident and staff file reviews and found both were in compliance with regulatory requirements. An exit interview was conducted with AD. LPA is requesting the following documents be submitted to the Fresno CCL office by 4/15/2025: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.the state’s words, verbatim · CDSS document, Mar 28, 2025

Allegation investigated: Staff inappropriately restrained the residents

On January 9, 2025, Licensing Program Analyst (LPA), R Bruce conducted a subsequent complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff, clients family, hospice worker, and LPA also obtained and/or reviewed facility records. It was determined based on the interviews, photographs, and records review that the above allegation is SUBSTANTIATED. Facility did inappropriately restrain a resident in her wheelchair utilizing a bed sheet tied around the client and chair to prohibit and prevent client from falling. There was no indication in the client's file that the doctor or family was made aware or approved. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 24-AS-20241003151606

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(1) · Plan of correction due date: Jan 17, 2025

Postural Support : a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal..., Postural supports may be used under the following conditions.(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance... This requirement was not met as evidenced by The client was tied to her wheelchair with a bedsheet and not an approved postural support device. There was also no approval from her physician for the restraint utilized. This poses a potential risk to the health, safety and personal rights of the client in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Facility stated they will provide training to staff on proper and improper restraints. Going forward documentation/approval from the doctor and family will be obtained and placed in the client's file when any postural support is used. Proof of training to be submitted to CCL by the due date of January 17, 2025. Proof will include a sign in sheet, length of training, who provided training, topics covered and who attended.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with Administrator, Jethronel Lazaga (AD) and explained the purpose of the visit. Facility was toured inside and outside with AD. Resident rooms contained required furnishings and lighting. This facility has 6 resident bedrooms and 5 bathrooms. LPA observed required items in bathrooms with hot water measuring between 106.7.1 to 114.4 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Medications are centrally stored and locked in closet near the kitchen. Cleaning supplies are stored in locked laundry room. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit is located in medication storage closet and found to contain required items. Fire Extinguishers are located throughout the facility and were serviced in 2/20/2024. Facility has a sprinkler system. Per Licensee, Smoke and Carbon Monoxide detectors are a combo alarm and are tested annually by AAA Quality Services fire safety company, the latest inspection was conducted on 2/20/2024. LPA conducted resident and staff file reviews and interviews. An exit interview was conducted with AD. LPA is requesting the following documents be submitted to the Fresno CCL office by 3/28/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.the state’s words, verbatim · CDSS document, Mar 14, 2024

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.