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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201833
Report Date: 01/10/2025
Date Signed: 01/10/2025 02:43:55 PM

Document Has Been Signed on 01/10/2025 02:43 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/
DIRECTOR:		ABIGAIL LORIMERFACILITY TYPE:
735
ADDRESS:7330 PRINCEVALLE STREETTELEPHONE:
(408) 842-1960
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Lilian BufiTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator (ADM), Lilian Bufi.

Upon arrival to the facility, there was 1 resident present with 1 staff member. LPA toured the facility with ADM to include the entrance, living room, kitchen, dining room, 5 resident bedrooms, bathrooms, backyard, and shed. The shed is being used for storage items. Facility temperature maintained at 73 degrees Fahrenheit. Facility has carbon monoxide detector and smoke alarm present. Fire extinguisher last serviced on 01/07/2025. All fire exit routes are free and clear of obstruction. All present staff are fingerprint cleared and associated to the facility.

5 out of 5 resident bedrooms observed well-kept and no observation of foul order. Bedrooms observed with proper furniture, linens, and adequate lighting. Bathrooms observed well-kept. Shower contains non-slip floors and grab bars. The hot water temperature measured in a bedroom #1 measured at 110.0 degrees F and the hallway bathroom #3 and #4 measured at 109 degrees F.

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 in the kitchen maintained at 40 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. In the kitchen, LPA observed a cockroach crawl out of one of the cabinets. The ADM immediately removed and discarded the insect.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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: ABBY'S HOME
FACILITY NUMBER: 435201833
VISIT DATE: 01/10/2025
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ADM states that they occasionally observe cockroaches in the kitchen area and states they have a pest control company that services the facility quarterly. ADM states the last service was completed in December 2024. LPA observed the pest control invoice record. Food items in the kitchen were observed covered and/or sealed in a plastic container. The counters were clean and there was no left over food crumbs or open food observed in the kitchen. The kitchen did not have a foul odor of spoiled food. LPA advised the ADM to deep clean the kitchen to include but not limited to the inside of the cabinets and drawers and ensure all food items are sealed to avoid attracting insects to the kitchen. ADM stated understanding.

Facility has an updated infection control plan. Facility staff were provided training on infection control.

Facility has an updated emergency disaster plan. Emergency lighting observed on the wall. 6 out of 6 residents has a grab and go backpack which contains a face sheet, non-perishable foods and clothing. Emergency drills are completed quarterly and the last drill was completed in December 2024.

4 residents files were reviewed. 4 out of 4 residents files were complete and updated. 4 residents centrally stored medication and centrally stored medication records observed maintain. 4 out of 4 residents had P & I money in the form of cash. 4 residents P & I money observed maintained with all money accounted for.

4 staff files were reviewed. 4 out of 4 staff files observed complete to include annual training.

Documents were requested to update the facility file by 01/24/2025: Lease agreement, LIC400, LIC402, LIC200 (if applicable), Administrator Certificate, and LIC500.

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. Page 2 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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