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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200399
Report Date: 03/05/2025
Date Signed: 03/05/2025 03:58:40 PM

Document Has Been Signed on 03/05/2025 03:58 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/
DIRECTOR:		LILIBETH ORDINIZAFACILITY TYPE:
735
ADDRESS:3327 SAN MARCO COURTTELEPHONE:
(510) 972-0866
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Lilibeth OrdinizaTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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On this day at around 1:10 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Norberto Gonzalez. LPA explained to Gonzalez the purpose of the visit. The Administrator was informed over the phone about the visit. The Administrator arrived at the facility at around 1:25 pm.

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 6/4/2024. 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. Medications were observed locked in a cabinet.

At 1:35 pm, 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 1/20/2025 and last earthquake drill was done in June 2024.

At around 2:30 pm, 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. At 2:35 pm, LPA reviewed medications and Medications Administration Records(MAR). continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 019200399
VISIT DATE: 03/05/2025
NARRATIVE
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Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in Civil Penalties.

Exit interview was conducted with Elvis Ordiniza, who was authorized by the Administrator to sign the report. Appeal Rights and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2025 03:58 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/05/2025 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ABBY'S ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having chemicals and sharp objects unlocked in the cabinet under the sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Cabinet was locked during the visit. This deficiency is cleared.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water measured at 123.4 Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Hot water was adjusted to 117 Fahrenheit during the visit. Deficiency is cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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