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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201834
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:08:28 PM

Document Has Been Signed on 01/25/2024 02:08 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:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lilian BufiTIME COMPLETED:
02:10 PM
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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, garage, 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 and visitation guidelines. LPA observed the facility license, complaint poster, personal rights, and COVID-19 related posters. Facility temperature maintained at 70 degrees Fahrenheit. Facility has carbon monoxide detector present. Fire extinguisher last serviced on 01/24/2024.

4 out of 4 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.

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 60 degrees Fahrenheit. Freezer temperature maintained at below 0 degrees Fahrenheit. The facility also has a refrigerator and freezer located in the garage that is only used for staff. The garage refrigerator temperature maintained at 20 degrees Fahrenheit and freezer maintained at 0 degrees Fahrenheit. Licensee plans to buy a new refrigerator for the kitchen. Staff immediately checked the food quality of the food inside the kitchen refrigerator and moved the items to the garage refrigerator. ADM was advised.

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)
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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: TRINITY HOUSE
FACILITY NUMBER: 435201834
VISIT DATE: 01/25/2024
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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.

2 staff members were interviewed.

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: 01/25/2024
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)
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