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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202139
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:06:57 PM

Document Has Been Signed on 06/20/2024 04:06 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 RCF, INC.FACILITY NUMBER:
435202139
ADMINISTRATOR/
DIRECTOR:
OKON A. & INI UBOHFACILITY TYPE:
735
ADDRESS:1454 RUE AVATI DR.TELEPHONE:
(408) 505-1660
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Janet BarbadilioTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Janet Barbadilio.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the kitchen area had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed locked cabinets for medications, sharps, and cleaning products. The first aid kit was reviewed and found to be complete.

LPA Marrufo toured three out of three resident rooms and found each room to have available bedding and clothing storage areas. Each bedroom had working lights. The smoke detectors in each bedroom and in the hallways and living room area functioned properly when tested.

LPA toured the bathroom and found the water temperature was at 119 F. The bathroom had available soap and paper towels.

LPA Marrufo toured the outside area and found the exit was clear of obstructions. LPA reviewed the Personal and Incidental Money Logs and Centrally Stored Medication and Destruction Records Logs for six out of six residents and found them to be complete. LPA Marrufo reviewed 6 out of 6 residents records and found them to be complete. LPA Marrufo reviewed the Administrator's records and 4 staff records and found the 4 staff records were missing an LIC9052 Employee Rights form.

An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Janet Barbadilio and a copy of tihs report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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