430707115-1-22-2025-26-AS-CDOS-DD6U7N-20250122142012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430707115
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:20:19 PM

Document Has Been Signed on 01/22/2025 02:20 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 #1		FACILITY NUMBER:	430707115
ADMINISTRATOR/ DIRECTOR:	ABRAHAM LONGORIA		FACILITY TYPE:	735
ADDRESS:	10855 DEBRUIN WAY		TELEPHONE:	(408) 848-4379
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 18		CENSUS: 12	DATE:	01/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Abraham Longoria		TIME VISIT/ INSPECTION COMPLETED:	02:25 PM

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) Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator, Abraham Longoria. During visit, LPA toured Becker House (South Valley Ranch #1) with the ADM to include the kitchen, dining room, resident bedrooms, bathrooms, common areas, and exterior. Facility temperature maintained between 72 - 74 degrees F. All fire exit routes were free and clear of obstruction. Emergency exit routes facility sketch posted throughout the hallways. Fire extinguishers last serviced on 01/07/2025. Carbon monoxide detector present. AED last serviced on 01/07/2025. First aid kit observed throughout the facility. Staff present are fingerprint cleared and associated to the facility. Kitchen observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator in the kitchen maintained at 36 degrees F. Freezer temperature located in the hallway maintained at 10 degrees F around 9am and 11am. At 2:00pm, the freezer temperature was measured at 1 degree F. The facility has a log posted on the freezer door where NOC shift staff records the temperature, however the freezer temperature was not being logged after 1/7/25. ADM was advised. LPA and ADM entered into room #4, 5, 7, and 10. Resident bedrooms equipped with beds, linens, adequate lighting, night stands, and closet space. LPA observed full length bed rails in bedroom #4, however only one of the rails was positioned upwards while the other rail was not in use. LPA interviewed the resident and there was no signs of mistreatment. See LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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: 01/22/2025

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Based on record review, the resident is not under hospice but has a physician's order for the use of full bed rails. LPA observed the facility does not have prior licensing approval for the full bed rails. ADM states a plan to follow-up with the resident's physician if the full rails are needed. LPA advised ADM of the exception request requirements should the resident utilize the full length bed rails per the physician.

Bathrooms equipped with grab bars, non slip floors, shower chairs, and hygiene supplies. The bathroom hot water temperature measured at 106 and 112 degrees F.

LPA reviewed 4 resident files. 4 out of 4 resident files were complete and up-to-date. 2 out of 4 residents had a restricted health condition care plan on file. ADM stated the restricted health condition care plans are reviewed with the resident and/or resident's authorized representative but the care plan did not contain a signature. LPA advised to include a page for the staff and resident and/or authorized representative to sign. 4 out of 4 resident's P&I money was counted with the ADM and staff. 4 out of 4 resident's P&I money was complete and all money was accounted for.

4 out of 4 resident's centrally stored medication and records were reviewed with staff and ADM. 4 out of 4 resident's centrally stored medications and records were complete. LPA observed the medications contained start dates.

4 resident's staff files were reviewed. Staff files are complete and up to date. Staff are provided annual training.

Facility an infection control plan. Facility has an emergency disaster plan. LPA observed the emergency supplies to include flashlights, batteries, and first aid kit.

No deficiency was cited per California Code of Regulations, Title 22. Advisory notes 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: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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