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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201833
Report Date: 01/24/2023
Date Signed: 01/24/2023 02:30:33 PM

Document Has Been Signed on 01/24/2023 02:30 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: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:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lilian BufiTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Lilian Bufi.

No clients observed on site and were attending day program. During visit, LPA toured the facility to include the kitchen, living room, resident rooms, bathrooms, and backyard. All fire exit routes were free and clear of obstruction. Facility temperature maintained at 66 degrees Fahrenheit. Fire extinguishers were up to date and serviced in January 2023. All staff present are fingerprint cleared and associated to the facility.

Facility has a designated entry point for symptom screening, temperature check, and sign in for all visitors and staff. Special visitor sign posted at the entry. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. LPA observed facility's Personal Protective Equipment (PPE) supplies. Staff are N95 fit tested. LPA observed the staff training record on infection control conducted on January 10, 2023. Facility monitors the residents temperature and symptoms multiple times daily. LPA reviewed the facility's policy and procedures to isolation and visitation. The following posters observed to include but not limited to social distancing, cough etiquette, and feeling ill.

At 01:12pm, LPA observed ceiling damaged which was caused by the heavy rains during the storm at the beginning on January 2023. See LIC9102 for more information.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Administrator, Lilian Bufi and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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