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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707540
Report Date: 11/29/2021
Date Signed: 11/29/2021 12:24:01 PM

Document Has Been Signed on 11/29/2021 12:24 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LEARNING SERVICES DAY TREATMENT ACTIVITY PROGRAMFACILITY NUMBER:
430707540
ADMINISTRATOR:KAYREE SHREEVEFACILITY TYPE:
775
ADDRESS:10855 DE BRUIN WAYTELEPHONE:
(408) 848-4379
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 28CENSUS: 22DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lindsay BlakeleyTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Lindsay Blakeley, Clinical Specialist.

LPAs toured the campus inside and outside to include the central entry point, Becker House, Treatment Center, Casa Castillo, and bathrooms. All fire exit routes were free and clear of obstructions. Toxins, cleaning supplies and sharp objects are secured.

COVID-19 Booster Clinic is scheduled for 12/06/2021 for all staff and residents.

Facility observed to have designated entry point for COVID-19 symptom screening located in the Therapy Center. Bathrooms observed to be supplied with hygiene products. Hand washing signs were posted in bathrooms. Hand sanitizer available to clients, staff, and visitors. LPAs observed the following posters to include: symptoms of COVID, social distancing, visitor policy, stop the spread of germs, and cleaning. LPAs observed supply of Personal Protective Equipment (PPE).

LPAs reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, training, and N95 fit testing.

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

LPAs reviewed report with Lindsay Blakeley and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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