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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707115
Report Date: 06/22/2023
Date Signed: 06/22/2023 01:52:52 PM

Document Has Been Signed on 06/22/2023 01:52 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: DATE:
06/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Abraham LongoriaTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the case management – incident visit. LPA met with Administrator, Abraham Longoria.

On 06/15/2023, the Department was made aware of a resident (R1) who passed away at the facility under hospice care services. Hospice care pronounced the death, and the mortuary was contacted for further arrangements.

Per the report, the family’s wishes were for R1 to pass away comfortably at the facility. R1’s family was in contact with the hospice care agency to sign required documents to ensure R1’s wishes. The facility was provided documents from the hospice care agency.

Upon review of the facility’s file, the facility was not granted a hospice care waiver from the Department. On 06/19/2023, the Administrator was contacted who confirmed the facility does not have an approved hospice care waiver. Administrator was advised and provided information on how to request for a hospice care waiver from the Department.

Documents were obtained during visit to include R1's hospice care documents.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Administrator, Abraham Longoria and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 01:52 PM - It Cannot Be Edited


Created By: Christine Dolores On 06/22/2023 at 01:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LEARNING SERVICES - SOUTH VALLEY RANCH #1
FACILITY NUMBER: 430707115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2023
Section Cited
CCR
85075.2(a)

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(a) In order to accept or retain terminally ill clients and permit them to receive care from hospice, the licensee shall have requested in writing and been granted a Facility Hospice Care Waiver from the Department. The licensee’s written request shall include, but not be limited to, the following: This requirement is not met as evidenced by:
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Licensee will request a hospice care waiver to the Department by 06/29/2023. Licensee will submit the request for hospice care to LPA Dolores by POC due date.
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Based on observation, interview, and record review the licensee did not ensure to obtain a granted hospice waiver from the Department prior to retaining a resident (R1) under hospice care which poses/posed a potential health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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