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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201834
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:22:22 PM

Document Has Been Signed on 02/24/2022 02:22 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:TRINITY HOUSEFACILITY NUMBER:
435201834
ADMINISTRATOR:LILIAN BUFIFACILITY TYPE:
735
ADDRESS:836 WELBURN AVE.TELEPHONE:
(408) 846-5160
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 4CENSUS: 4DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:LILIAN BUFITIME COMPLETED:
02:30 PM
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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 4 private resident rooms and 2 bathrooms. 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.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Note provided.

This report was reviewed with Administrator, Lilian Bufi and a copy of this report 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)
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