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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201834
Report Date: 01/24/2023
Date Signed: 01/24/2023 03:16:05 PM

Document Has Been Signed on 01/24/2023 03:16 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: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:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Lilian BufiTIME COMPLETED:
03:20 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.

During visit, LPA toured the facility to include the living room, kitchen, dining room, resident rooms, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. 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. 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 staff clean and disinfect multiple times daily and as needed. 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 keep the facility clean.

An updated copy of the facility's LIC610D and LIC500 was requested to send to the Department by Monday, 1/30/2023.

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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