Trinity Care Home 4

Type of visit: Required - 1 Year

On 9/8/2025 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Backup Administrator, Marjorie Osia and explained the purpose of the visit. Administrator arrived at 11:00am. The facility’s fire clearance was approved for all non-ambulatory of which one may be bedridden. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication were locked and sharps were not locked and accessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/29/2025. Emergency Disaster Plan was last posted on 9/6/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/7/2026. At 10:00am, LPA reviewed 5 of 5 residents records. At 10:35 am, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. Report continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed unlocked cleaning supplies under kitchen sink, laundry room door open with unsecured chemicals, and scissors in hall bathroom sink pullout LPA issued a Technical Violation because LPA observed food that requires refrigeration after opening is not being properly stored (ketchup, tuna spread, pimiento olives, and tartar sauce) Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 10/01/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Updated facility sketch Current Administrator’s Certificate The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 8, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above in having dangerous chemicals and sharps accesible to residents which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Facility secured dangerous items POC clear.

Type of visit: Case Management - Other

On 6/17/2026 at 2:30PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter. LPA met with Caregiver, Mary Joyce Oliaguer and explained the purpose of the visit. Backup Administrator Marjorie Labay was notified via phone and approved the caregiver to sign off on the report and accept the exclusion notification. Management staff Jessica Licup arrived durring visit. During visit, LPA hand delivered the immediate exclusion letter for S1 to Caregiver, Mary Joyce Oliaguer. S1 was scheduled to work at the facility on the night shift and was removed from all schedules. No deficiencies are being cited on this date.the state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Case Management - Legal/Non-compliance

On 11/13/2025 at 9:00 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management to ensure that the requirements of the 07/29/2025 stipulation are being followed. LPA met with Gina Licup, Licensee/Administrator and explained the purpose of the visit. During this visit, the LPA observed: (1) Licensee is enrolled for the eequired additional 20hrs of training. Licensee is complying with all aspects of stipulation. No citations issued during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Required - 1 Year

On 9/18/2025 at 11:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Backup Administrator, Marjorie Osia and explained the purpose of the visit. Administrator was out of town during inspection. The facility’s fire clearance was approved for all non-ambulatory of which one may be bedridden. LPA toured facility with Marjorie including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 124.2 degrees Fahrenheit and 125.1 degrees Fahrenheit in room 4. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were not locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/18/2024. Emergency Disaster Plan was last posted on 9/3/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 9/15/2025. At 12:00pm, LPA reviewed 6 of 6 residents records. At 12:35 am, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. Report continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed ADUs in the backyard being utilized by staff that are not fire cleared and are not listed on the facility sketch. LPA observed the hot water at 125.1 and 124.2 degrees F LPA observed unlocked prescription medications in medication cups in the kitchen drawer as well as used needles unlocked under the kitchen sink in a plastic container. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Office

On 8/6/2025 at 9:00 AM, the Oakland CCLD Adult & Senior Care Regional Offices conducted a virtual meeting with representatives for Trinity Care Home 4 to review the Stipulation Agreements for the facilities, dated 7/29/2025. CCLD Licensing Program Manager, CCLD, Oakland ASC, Yvonne Flores-Larios discussed the stipulations and their status implementation; and questions and clarifications were addressed. Meeting Participants: • Yvonne Flores-Larios – Licensing Program Manager, CCLD, Oakland ASC • Alona Gomez – Licensing Program Analyst, CCLD, Oakland ASC • Gina Licup – Licensee/ Administrator, Trinity Care Home 4 • Marjorie Osia – Administrator, Trinity Care Home 4 This report was emailed to Gina Licup for signature, to be returned to CCLD Oakland Regional Office.the state’s words, verbatim · CDSS document, Aug 6, 2025

Allegation investigated: Facility staff engaging in inapproriate relationship with resident

On 4/16/2025 at 1:20PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver complaint findings for the above allegations. LPA met with Licensee/Administrator, Gina Licup and explained the purpose of the visit. During the investigation LPA interviewed staff, residents, reviewed care plans, admissions agreements, physicians reports for R1, and reviewed documents. On the allegation “Facility staff engaging in inappropriate relationship with resident” LPA found the following : Report Continues on LIC9099-C Substantiated On 1/10/2025 While interviewing the Administrator/Licensee Gina Licup, they confirmed that they along with backup administrator Marjorie Osia were made of aware of S1 having married R1 while on an outing on 2/9/2024. Licensee states that they advised S1 and R1 to not disclose the marriage to other residents and staff. On 7/25/2024 LPA interviewed both R1 and S1. R1 disclosed that S1 asked them to marry them multiple times and that they initially said no but later changed their mind. R1 told LPA that the first time S1 asked them to marry it was after living at the facility for a few months and after they said no S1 asked again a few months later. S1 confirmed that they did ask R1 to marry them and they were initially hesitant but later agreed when they asked again. On 7/25/2024 LPA interviewed the Assistant Administrator Marjorie Osia who stated that they were aware of the relationship between R1 and S1. Licensee and Assistant Administrator found out about the marriage approximately a month after R1 and S1 were married. Assistant Administrator stated that they were going to make an abuse report but decided not to so that the Licensee/Administrator could handle the situation. Livensee/Administrator states that they never reported the relationship because R1 does not have a dementia diagnosis however Administrator also disclosed that R1 had recently been financially abused by their previous responsible party which is also why the administrator states that they did not inform R1’s responsible party/emergency contact. LPA also obtained copies of the Employee handbook and reviewed that it instructed employees to not use their position for personal gain. On 1/10/2025 Administrator stated that they fired S1 on 10/31/2024 because of the ongoing investigation of the allegation “Facility staff engaging in inappropriate relationship with resident” on 11/31/2024 R1 left the facility. Administrator states that S1 and R1 now live together at R1’s home. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D Exit interview conducted. Appeal Rights and a copy of this report providedthe state’s words, verbatim · CDSS document, Apr 16, 2025 · control 15-AS-20240715150655

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(D) · Plan of correction due date: Apr 23, 2025

(a)Each licensee shall furnish... reports...including, but not limited to, the following (D)Any incident which threatens...resident...by staff or...any resident. This requirement was not met as evidence by: Based on LPA's interviews, Licensee failed to report S1 marrying R1 which posed a potential personal rights and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: By POC Licensee agrees to review regulation and attend/provide additional training with thyself and staff and notify CCL.

Type of visit: Case Management - Other

On 4/16/2025 LPA A Gomez and conducted a case management visit while at the facility for complaints 15-AS-20240715150655. LPA met with Licensee/ Administrator Gina Licup and explained the purpose of the visit. While conducting the complaint investigation LPA found that S1 married R1 and the Licensee/Administrator and backup Administrator found out and did not report it to Licensing. Licensee stated that they did not think that they had to report the incident because R1 did not have a dementia diagnosis however the Administrator did advise S1 and R1 to not disclose the marriage to other residents or staff. Because Licensee/Administrator and backup Administrator failed to report the incident and asked S1 and R1 to not disclose their marriage LPA is citing for "Administrator Qualifications" The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(5) · Plan of correction due date: Apr 23, 2025

(d) The administrator shall...apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidence by: Based on LPA's interviews, Licensee failed to report S1 marrying R1 and then advised them not to tell anyone which posed a potential personal rights and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: By POC Licensee agrees to review regulation and attend additional training with thyself and backup administrator and notify CCL

Type of visit: Required - 1 Year

On 10/18/2024 at 10:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Backup Administrator, Marjorie Osia and explained the purpose of the visit. Administrator was out of town during inspection. The facility’s fire clearance was approved for all non-ambulatory of which one may be bedridden. LPA toured facility with Marjorie including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 107.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/07/2023. Emergency Disaster Plan was last posted on 9/20/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 9/20/2024. At 10:40am, LPA reviewed 6 of 6 residents records. At 11:15 am, LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 1:35PM. Upon arrival, LPA met with caregiver Edilberto Cama. Assistant Administrator, Marjorie Osia later arrived at 2:15pm, Administrator, Jessica Licup arrived at 2:20PM and Licensee Gina Licup arrived at 4:00pm. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week nonperishable and 2-day perishable supply of food. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/07/2023. Emergency Disaster Plan was last posted on 9/10/2023. First aid kit was observed to be complete. Fire drill was last conducted on 10/15/2023. LPA reviewed 5 staff records and 5 of 5 staff are associated and have current first aid training. LPA reviewed 5 residents record and a sample of resident's medications were reviewed. Report continues on LIC 809-C Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/31/2023: LIC 500 Personnel Report Updated Facility Sketch Exit interview conducted with Licensee and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 14, 2023