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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707115
Report Date: 04/06/2022
Date Signed: 04/06/2022 11:49:12 AM

Document Has Been Signed on 04/06/2022 11:49 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LEARNING SERVICES - SOUTH VALLEY RANCH #1FACILITY NUMBER:
430707115
ADMINISTRATOR:KAYREE SHREEVEFACILITY TYPE:
735
ADDRESS:10855 DEBRUIN WAYTELEPHONE:
(408) 848-4379
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 18CENSUS: 12DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Abraham LongoriaTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a required 1-year annual inspection to focus on infection control. LPA met with Administrator, Abraham Longoria.

During visit, LPA toured the Becker House to include the dining room, bathrooms, activity room, resident rooms, and exterior. Facility observed to have a designated entry point for COVID-19 symptoms screening located in the Therapy Center for all visitors and staff. All fire exit routes were free and clear of obstruction.

Bathrooms observed to be supplied with hygiene products, paper supplies, and hand washing signs. Hand sanitizer available throughout the facility. The following posters were observed to include: symptoms of COVID, social distancing, visitor policy, and stop the spread of germs. Facility cleans and disinfect multiple times daily and as needed. Facility has a procedure in place for visitation. LPA observed supply of Personal Protective Equipment (PPE). All staff are vaccinated to include the booster, if eligible. All staff observed to be wearing a mask. LPA reviewed facility's policies and procedures to isolation and infection control training.

LPA advised facility to provide N95 fit testing to staff. LPA informed Administrator to submit Infection Control Plan to CCLD by 06/30/2022 and review PIN 22-13-ASC.

No citations were issued per the California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Abraham Longoria and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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