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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200399
Report Date: 04/22/2026
Date Signed: 04/22/2026 03:01:24 PM

Document Has Been Signed on 04/22/2026 03:01 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
OAKLAND ASC, 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:
04/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Onesty Hill, Direct Care Staff TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 04/22/2026 at 11:10 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator Lilibeth Ordiniza and explained the purpose of the visit. Administrator certificate is current. Ordiniza could not stay to sign the report and gave verbal authorization for Onesty Hill to sign the report. The facility’s fire clearance was approved for 6 ambulatory only.

LPA toured the facility including inside and out but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms and 1 office space, of which 6 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 65 degree Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the clients. The supply of extra hygiene's was available for clients.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 05/22/2025. First aid kit was observed to be complete. Fire drill was last conducted on 04/04/2026.

At 11:58 AM, 6 of clients’ records were reviewed. At 12:23 PM, 4 staff records were reviewed and 4 of 4 have current first aid training and 4 of 4 associated with the facility. LPA reviewed two clients' P&I money with log. LPA reviewed two samples of clients’ medications.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/22/2026 03:01 PM - It Cannot Be Edited


Created By: Patricia Manalo On 04/22/2026 at 02:15 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: 04/22/2026

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 by having cleaning chemicals such as scrubbing bubbles, bubbles foaming bleach, and Lysol Wipes which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/23/2026
Plan of Correction
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The Administrator locked the items during the visit. Deficiency cleared.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(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 by having the hot water temperature measured at 140.4 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/23/2026
Plan of Correction
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By POC date, the Administrator agrees to have the hot water temperature measured within range and send proof to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/22/2026 03:01 PM - It Cannot Be Edited


Created By: Patricia Manalo On 04/22/2026 at 02:15 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: 04/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 by having a tv out by the front door, a foul odor coming from one of the client's room and into the hallway, and one of the client's bathroom sink leaking which poses a potential health and personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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By POC date, the Administrator agrees to discard the tv, repair the sink, and create a plan for the foul odor coming out of the client's room and hallfway. LPA will verify that the plan is being implemented and the smell has reduced.
Type B
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having a staff member sleep in the office room per approved facility sketch and not the designated staff room which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 04/29/2026
Plan of Correction
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By POC date, the Administrator agrees to have the staff member move to the designated staff room per approved facility sketch. Proof of correction will be sent to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 04/22/2026 03:01 PM - It Cannot Be Edited


Created By: Patricia Manalo On 04/22/2026 at 02:15 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: 04/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a complete and current records for all the clients' in care which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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By POC date, the Administrator agrees to have the clients' files completed and send to CCLD for review.
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

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 by having rotten cucumbers and squash which posed a potential health and safety risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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By POC date, the Administrator agrees to have an in-service on properly storing and labeling food. In addition, the Administrator discarded the rotten food.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ABBY'S ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200399
VISIT DATE: 04/22/2026
NARRATIVE
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Continued from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/30/2026:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 610D Emergency Disaster Plan
Infection Control Plan

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:15 AM, LPA observed a tv outside by the front door. At 11:30 AM, LPA observed a foul odor in the client’s room and into the hallway. At 11:42 AM, LPA observed one of the client's bathrooms sink leaking.

At 11:42 AM, LPA observed unlocked cleaning chemicals such as scrubbing bubbles, bubbles foaming bleach, and Lysol Wipes.

At 11:46 AM, LPA observed that the cucumber and squash had mold.

At 12:00 PM, LPA observed the hot water temperature measured at 140.4 degrees Fahrenheit.

At 1:55 PM, record review revealed that the clients' files are incomplete.

At 2:06 PM, LPA observed that a staff is residing in the office room per facility sketch.

The Facility was 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 with Hill. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC809 (FAS) - (06/04)
Page: 8 of 8