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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201736
Report Date: 06/18/2021
Date Signed: 06/30/2021 10:07:12 AM

Document Has Been Signed on 06/30/2021 10:07 AM - 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ABORN ADULT CARE HOMEFACILITY NUMBER:
435201736
ADMINISTRATOR:DR. SHACY LEE RIVERAFACILITY TYPE:
735
ADDRESS:2868 ABORN ROADTELEPHONE:
(408) 223-1108
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 6DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shacy Lee RiveraTIME COMPLETED:
02:45 PM
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On 06/18/2021 at 1:45 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced Annual Required 1 Year visit. LPA met with Administrator Dr. Shacy Lee Rivera.

LPA toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log to document temperature and screening questions. Universal precautions, COVID-19 protocols, and social distancing guidelines were posted throughout the facility. Restrooms had hand soap and paper towels readily available. Hand washing sign was posted at all hand washing stations.

Staff were observed wearing a mask and following COVID-19 protocols. Facility observed to have adequate supply of PPE.

No deficiencies were cited during today's visit.

This report was reviewed with Administrator Dr. Shacy Lee Rivera and a copy was provided to Administrator Dr. Shacy Lee Rivera.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Anna Bui
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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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