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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201834
Report Date: 01/10/2025
Date Signed: 01/10/2025 11:32:04 AM

Document Has Been Signed on 01/10/2025 11:32 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:TRINITY HOUSEFACILITY NUMBER:
435201834
ADMINISTRATOR/
DIRECTOR:		LILIAN BUFIFACILITY TYPE:
735
ADDRESS:836 WELBURN AVE.TELEPHONE:
(408) 846-5160
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 4CENSUS: 4DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Lilian BufiTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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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 2 staff members. 1 out of 2 staff members was off duty who assisted LPA with a tour while waiting for the ADM to arrive. LPA toured the facility with staff to include the entrance, dining room, living room, kitchen, 4 resident bedrooms, 2 bathrooms, garage, and backyard. Facility temperature maintained at 70 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.

4 out of 4 resident bedrooms observed well-kept and no observation of foul order. Bedrooms observed with proper furniture, linens, adequate lighting and functional sliding doors. Bathrooms observed well-kept. Shower contains non-slip floors and grab bars. The hot water temperature measured in a resident's private bathroom measured at 111.0 degrees F and the hallway bathroom measured at 112 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 34 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. PRN medication observed inside a locked box inside the refrigerator. Page 1 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
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 2
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: 01/10/2025
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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. 4 out of 4 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. 3 out of 4 residents had P & I money in the form of cash. 3 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.

1 resident and 1 staff was interviewed.

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.

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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
LIC809 (FAS) - (06/04)
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