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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707540
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:55:54 PM

Document Has Been Signed on 11/21/2024 01:55 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/
DIRECTOR:		KAYREE SHREEVEFACILITY TYPE:
775
ADDRESS:10855 DE BRUIN WAYTELEPHONE:
(408) 848-4379
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 28CENSUS: DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Abraham LongoriaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator, Abraham Longoria.

During visit, LPA toured the day treatment activity room located in Becker House (South Valley Ranch #1) and the therapy room. The day treatment program only has 1 participant. The day treatment activity room is utilized as a shared activity room for the residential residents. All fire exit routes were free and clear of obstruction. Fire extinguisher last served on 01/18/2024. Facility temperature maintained at 71 degrees F. The therapy room is equipped with an AED (Automated External Defibrillator) and first aid kit. The AED device was last serviced in November 2024. LPA observed staff are trained on the use of the AED. Facility has an infection control plan and emergency disaster plan. Facility conducts the emergency drills monthly.

1 client file was reviewed and observed complete to include an admissions agreement, physician's report, needs and services plan, consent form, personal rights, and functional capabilities assessment. No medications are held for this client. 1 staff file was reviewed and observed complete to include a fingerprint clearance, health screening, TB result, job application, 1st Aid Certification, and update PT license.

The change of Administrator documents were requested by 11/29/2024 to include the Board Letter, LIC308, LIC500, Resume or LIC501, DL/ID, and LIC9182.

No deficiencies were cited per California Code of Regulations, Title 22. 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: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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