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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201736
Report Date: 05/24/2024
Date Signed: 05/24/2024 05:00:10 PM

Document Has Been Signed on 05/24/2024 05:00 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ABORN ADULT CARE HOMEFACILITY NUMBER:
435201736
ADMINISTRATOR/
DIRECTOR:
ARIELLE TEODOROFACILITY TYPE:
735
ADDRESS:2868 ABORN ROADTELEPHONE:
(408) 223-1108
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 6DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Arielle Teodoro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 5/24/2024 at 3:30. P.M. Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Manuel Monter arrived and conducted an unannounced required 1 year inspection visit at the facility and were greeted by 3 staff (S1 to S3). The administrator was not in the facility at the time of the visit, the staff called the administrator (ADM) Arielle Teodoro and ADM arrived soon thereafter.

The facility is an Adult Residential Facility (ARF) licensed to serve ages 18 to 59 years of age 6 may be non-ambulatory. Currently there are 6 out of 6 ambulatory residents with developmental disability. 5 staff were present at the time of the visit. 1 out of 6 resident was in the day program during the visit. 5 out of 6 resident were in the facility.

At 3:33 p.m. LPAs toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents’ rooms, the facility does not have a staff room inside the facility. An additional dwelling unit (ADU) for staff use is located within the property. The backyard and walkways are free from any obstruction. LPA observed the Personal Rights disclosure visible to the visitors, residents and employees,

The temperature inside the home was at 72 degree F. LPA and ADM toured 3 resident bedrooms. LPA observed the rooms to have sufficient storage spaces to hold the resident’s personal belonging. 3 out of 3 residents’ room are shared room. are maintained, and free from debris.

The facility has smoke, fire and carbon monoxide alarm system, that is in good working condition. Exit doorways are not obstructed.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ABORN ADULT CARE HOME
FACILITY NUMBER: 435201736
VISIT DATE: 05/24/2024
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LPAs observed the 2 bathroom, that are used by staff and residents. LPA observed grab bars and floor has non-skid surface. LPAs observed bathroom has hard water stains on the bathroom floor and wall. ADM stated he/she will continue to take the hard water stain in the shower tub in bathroom near bedroom #3.

LPAs tested the water temperature for kitchen and bathrooms, water temperature was measured at 116 to 119 degree F. Dining, kitchen and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguisher was bought on 7/23/2023. Knives and sharps are locked and not easily accessible to residents in care.

LPAs and ADM inspected the laundry area. LPA observed the laundry area is located at the garage. The washer and dryer are in good working condition, the laundry area has a cabinet that stores laundry detergents and cleaning supplies are kept locked and not accessible to residents.

LPAs with ADM inspected the medication cabinet. LPA observed the medication room is locked and is not easily accessible. LPA observed the first aid kit is complete with scissors, bandages and creams. LPA observed that knives are in a locked cabinet.

LPAs reviewed facility record, 3 out of 3 staff record and 3 out of 6 resident record. Facility's fire drill training conducted on 3/4/2024, facility records are up to date. Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents’ files were reviewed to be complete. Residents' medications are labeled and current.

No deficiencies are cited during today's visit based on the California Code of Regulations (CCR) Title 22. a technical assistance was provided based during today's visit for the upkeep of the resident's bathroom. An exit interview was conducted with ADM Arielle Teodoro a copy of the report was provided.

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END OF REPORT
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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