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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707115
Report Date: 01/18/2024
Date Signed: 01/18/2024 04:27:01 PM

Document Has Been Signed on 01/18/2024 04:27 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:LEARNING SERVICES - SOUTH VALLEY RANCH #1FACILITY NUMBER:
430707115
ADMINISTRATOR:ABRAHAM LONGORIAFACILITY TYPE:
735
ADDRESS:10855 DEBRUIN WAYTELEPHONE:
(408) 848-4379
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 18CENSUS: 12DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Abraham LongoriaTIME COMPLETED:
04:30 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), Abraham Longoria.

During visit, LPA toured the facility with ADM to include the kitchen, pantry, dining room, medication room, office space, resident bedrooms, bathroom, and exterior.

All fire exits were free and clear of obstruction. Fire extinguishers last serviced on 01/18/2024. Carbon monoxide detector observed present and operable. Facility temperature maintained at 72 degrees Fahrenheit. LPA observed the facility has sufficient PPE supplies.

Kitchen observed with a lock on the door. Sharp objects and chemicals observed secured. Refrigerator temperature maintained at 37 degrees Fahrenheit. Freezer temperature maintained at 10 degrees Fahrenheit. ADM was advised. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Bathroom supplies with hygiene products, paper supplies, gloves, showers, grab bars, and non-slid floors.

Resident bedrooms observed with beds, clean linens, adequate lighting, night stands, and dressers. 3 out of 4 resident bedrooms observed contained half rails. LPA did not observe a physician's order for 1 out of 3 residents.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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: LEARNING SERVICES - SOUTH VALLEY RANCH #1
FACILITY NUMBER: 430707115
VISIT DATE: 01/18/2024
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LPA reviewed 4 resident files to include a medical assessment, TB result, updated and signed appraisal/needs and services plan, functional capabilities assessment, safeguard of personal properties and valuables, consent forms, and signed personal rights. LPA observed the facility's admission agreement did not include required information from Title 22 Regulations Section 80068(c). LPA advised ADM. LPA obtained a copy of the current admission packet and admission agreement.

LPA reviewed 4 staff files to include 1st aid certification, health screening report, TB result, and personnel record/job application. All staff present are fingerprint cleared and associated to the facility.

Facility has an emergency disaster plan. The last drill was conducted on October 28, 2023.

Due to insufficient time, LPA will return to the facility another day to continue the annual required 1-year inspection. This report was reviewed with Administrator, Abraham Longoria and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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