<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201833
Report Date: 01/25/2024
Date Signed: 01/25/2024 11:19:15 AM

Document Has Been Signed on 01/25/2024 11:19 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
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:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Lilian BufiTIME COMPLETED:
11:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator (ADM), Lilian Bufi.

1 resident present in the facility during the visit. LPA toured the facility with ADM to include the entrance, dining room, living room, kitchen, resident bedrooms, bathrooms, and backyard. All fire exit routes are free and clear of obstruction. All present staff are fingerprint cleared and associated to the facility.

Upon entrance, the facility has a visitor sign-in sheet. LPA observed the facility license, complaint poster, personal rights, and COVID-19 related posters. Facility temperature maintained at 68 degrees Fahrenheit. Facility has carbon monoxide detector present. Fire extinguisher last serviced on 01/24/2024.

5 out of 5 resident bedrooms observed with furniture to include a bed, adequate lighting, dressers, closet, and night-stands. Bathrooms supplied with hygiene products and paper supplies. The hot water temperature measured at 106 degrees Fahrenheit. Facility logs their hot water temperature daily.

Medication, disinfectants, and cleaning solutions observed locked. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 42 degrees Fahrenheit. Freezer temperature maintained at 16 degrees Fahrenheit. The items inside the freezer were observed frozen. ADM was advised. Facility has a weekly menu and monthly activities calendar observed posted.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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
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: ABBY'S HOME
FACILITY NUMBER: 435201833
VISIT DATE: 01/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility has an updated infection control plan. Facility staff were provided training on infection control. Facility has complete Personal Protective Equipment (PPE) supplies to include gowns, shields, gloves, masks, N95 masks, hand sanitizer, and disinfectant wipes.

Facility has an updated emergency disaster plan. Facility has emergency lighting. Staff has conducted emergency disaster drills quarterly. The last drill was conducted on December 2023.

3 residents files (R1 - R3) were reviewed. 3 out of 3 residents files contained an admission agreement, medical assessment, TB result, appraisal/needs and services plan, IPP, personal rights form, and safeguard of personal property and valuables form. R1 - R3's centrally stored medications and P&I money were inspected and observed maintained.

3 staff files (S1 - S3) were reviewed. 3 out of 3 staff files contained an updated 1st aid certification, fingerprint clearance, LIC501, LIC503, TB information, LIC9052, and training.

No residents and staff present during time of visit to conduct interviews.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Lilian Bufi and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/25/2024 11:19 AM - It Cannot Be Edited


Created By: Christine Dolores On 01/25/2024 at 11:05 AM
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: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the facility's freezer temperature was maintained at 16 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
1
2
3
4
Licensee will buy a new refrigerator/freezer appliance. Licensee will submit the proof of purchase and a picture of the new appliance by POC due date if 02/01/2024 to LPA Dolores.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3