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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707540
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:14:51 PM

Document Has Been Signed on 11/09/2022 02:14 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 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: 0DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Staci BettencourtTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrative Assistant, Staci Bettencourt.

During visit, LPA toured the day treatment activity room and gym. All staff observed wearing a face covering. Staff present are fingerprint cleared and associated to the facility.

Day treatment program is currently not operating due to the service not needed at this time. Once service is needed, the day treatment program will continue providing services.

Facility has a designated entry point for symptom screening and temperature check for all staff, visitors, and clients located in the main building. Hand sanitizer available at entry and throughout the facility. LPA observed facility's Personal Protective Equipment (PPE) supplies and PPE bins for isolation purposes. Staff are trained on infection control and have completed N95 fit testing. Facility clean and disinfect multiple times daily and as needed. The following posters observed to include, symptoms of COVID and social distancing.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Staci Bettencourt and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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