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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200399
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:35:06 PM

Document Has Been Signed on 03/07/2024 04:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ABBY'S ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200399
ADMINISTRATOR:LILIBETH ORDINIZAFACILITY TYPE:
735
ADDRESS:3327 SAN MARCO COURTTELEPHONE:
(510) 972-0866
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lilibeth OrdinizaTIME COMPLETED:
04:45 PM
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On this day at around 1 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Abigail Ordiniza. LPA explained Ordiniza the purpose of the visit. The Administrator was informed over the phone about the visit. The Administrator arrived at the facility at around 2:00pm.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining area, garage and backyard. The facility is a Level 4F home vendorized by the Regional Center of the East Bay (RCEB). LPA observed a fire extinguisher that appeared full and was last serviced on 5/31/2023. Smoke detectors and carbon monoxide detectors were tested and observed functional. There were sufficient supply of both perishable and non perishable foods. The facility has ample supply of warm blankets, sheets and towels available for use of the clients. First aid kit was inspected and observed complete and updated. Medications were observed locked in a cabinet.

LPA reviewed 5 staff and 5 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. The facility's last fire drill was conducted on 3/2/2024 and last earthquake drill was done on 1/2/2024.

P&I money and log were checked. LPA observed the facility has sufficient amount of surety bond to cover amount of money being handled at one time.

LPA reviewed medications and Medications Administration Records(MAR) with Ordiniza.

There is no deficiency noted during the visit. A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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