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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201833
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:21:40 PM

Document Has Been Signed on 02/24/2022 04:21 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ABBY'S HOMEFACILITY NUMBER:
435201833
ADMINISTRATOR:ABIGAIL LORIMERFACILITY TYPE:
735
ADDRESS:7330 PRINCEVALLE STREETTELEPHONE:
(408) 842-1960
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:LILIAN BUFITIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection and met with Administrator, Lilian Bufi.

During today's visit LPA toured the facility inside and outside to include living room, kitchen resident rooms, bathrooms, garage, and backyard. Facility has 5 resident rooms and 4 bathrooms. LPA observed 2 residents socially distanced in the living room and all staff observed to be wearing a surgical mask.

Facility observed to have designated entry point for COVID-19 symptom screening for all visitors and staff. Hand sanitizer available to residents and visitors. Bathrooms observed to be supplied with hygiene products, paper supplies, and hand-washing sign. LPA observed supply of Personal Protective Equipment (PPE).

LPA observed the following posters to include required face mask, social distancing, cough/sneeze etiquette, and feel ill. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility staff are trained on infection control to include donning and doffing. Staff are N95 fit tested.

The following documents were requested to send to LPA: LIC610D, LIC500, and Administrator Certificate.

Deficiencies cited during today's visit per California Code of Regulations, Title 22. See LIC809D. Advisory Note provided.

This report was reviewed with Administrator, Lilian Bufi and a copy of this report and appeal rights was provided
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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 3
Document Has Been Signed on 02/24/2022 04:21 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/24/2022 at 03:38 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ABBY'S HOME
FACILITY NUMBER: 435201833

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 and interview the licensee did not comply with the section cited above by not ensuring all gates for emergency exit are in good repair, making it hard to open and close gates in the case of emergency which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee will repair all gates to ensure gates will open and close easily. Licensee will submit plan of action statement to repair all gates via email by POC due date of 02/25/2022.
Type A
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 not ensuring window screen leading to the backyard to be in good repair making it difficult to exit in case of an emergency and resident room window screen to be in disrepair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee will repair window screen leading to backyard to ensure the door slides easily. Licensee will repair window screen in the residents room leading to the backyard. Licensee will submit proof of receipt via email to LPA by POC due date of 02/25/2022.
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:Jackie Jin
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


LIC809 (FAS) - (06/04)
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