<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202373
Report Date: 05/03/2024
Date Signed: 05/03/2024 10:39:51 AM

Document Has Been Signed on 05/03/2024 10:39 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 RCF, INC.- WILLIAMSFACILITY NUMBER:
435202373
ADMINISTRATOR/
DIRECTOR:		INI O. OR OKON A. UBOHFACILITY TYPE:
735
ADDRESS:1330 MICH BLUFF DRIVETELEPHONE:
(408) 476-8772
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 6DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Natividad BarbadilloTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year inspection. LPA met with lead DSP, Natividad Barbadillo.

During visit, LPA toured the facility with lead DSP to include the living room, kitchen, dining room, 3 resident bedrooms, 2 bathrooms, staff bedroom, garage, and backyard. 2 residents were present. 2 out of 2 staff present are fingerprint cleared and associated to the facility.

All fire exit routes were free and clear of obstruction. Facility temperature maintained at 71 degrees Fahrenheit. Fire extinguisher last serviced on 01/25/2024. Facility has a dual smoke detector and carbon monoxide detector.

Resident bedrooms observed with a bed, linens, night stand, closet space, and adequate lighting. Bathrooms observed with hygiene products. Showers observed with non-slid mat and grab bars. LPA was unable to obtain the facility water temperature due a broken water thermometer. The facility's hot water temperature was last recorded during an unannounced visit on 12/11/2023, and maintained at 110 degrees Fahrenheit. Fire place screened in the living room. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 36 degrees Fahrenheit. Freezer temperature maintained below 0 degrees Fahrenheit. Trash bin with lid observed in kitchen. Sharp objects, chemicals, disinfectants, and medications observed locked.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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 RCF, INC.- WILLIAMS
FACILITY NUMBER: 435202373
VISIT DATE: 05/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 LPA reviewed 3 resident files and observed them maintained to include an admission agreement, medical assessment, TB result, IPP and appraisal/needs and services plan, identification emergency information, consent forms, and personal rights. 3 out of 3 residents P&I money and centrally stored medications was reviewed with lead DSP, and observed to be maintained.

LPA reviewed 3 staff files to include a 1st aid certificate, health screening, TB result, personnel report, and training records.

Facility has an emergency disaster plan and infection control plan. Emergency drills are being conducted quarterly. LPA observed the facility's first aid kit to be complete.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with lead DSP, Natividad Barbadillo and Administrator Ini Okon Uboh and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2