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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707115
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:16:52 PM

Document Has Been Signed on 01/24/2024 04:16 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:
01/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Abraham LongoriaTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual continuation. LPA met with Administrator, Abraham Longoria.

Facility has an updated infection control plan. LPA observed staff are trained on infection control. LPA observed the missing physician's order for 1 out of 3 residents from visit on 01/18/2024. The physician's order for the postural support was dated in 2017. Facility has an AED machine. LPA observed staff are provided training on AED. LPA observed staff who assist residents with medications were provided annual training. Staff are provided training annually on topics relating to care and supervision.

Medication room observed locked. LPA reviewed 4 residents centrally stored medications and centrally stored medications records with the ADM. LPA recommended to write out start dates on the centrally stored medication records. LPA observed a few over-the-counter / PRN medications were not on the centrally stored medication record. The medications were being logged on their electronic medication administration record (MAR) to include the prescription number, dosage, and instructions. LPA reminded ADM of the importance of ensuring the centrally stored medication records were up-to-date to include over-the-counter / PRN medications.

Hot water temperature measured at 108 degrees Fahrenheit. LPA interviewed 4 staff members and 4 residents. During visit, LPA obtained proof of the freezer work order and cost estimate of the part ordered.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Abraham Longoria and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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