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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707864
Report Date: 06/22/2021
Date Signed: 06/22/2021 11:49:52 AM

Document Has Been Signed on 06/22/2021 11:49 AM - 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-SOUTH VALLEY RANCH#2FACILITY NUMBER:
430707864
ADMINISTRATOR:SHREEVE, KAYREEFACILITY TYPE:
735
ADDRESS:10855 DE BRUIN WAYTELEPHONE:
(408) 848-4379
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 10CENSUS: 10DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:David HollandTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Infection Control site visit today. LPA met with Vice President of Operations (VP) David Holland and Administrator (ADM) Rosa Sanchez.

LPA toured the facility inside and out. Facility was observed to have a designated entry point for universal symptom screening including temperature check and a questionnaire log. Hand sanitizers were available to residents, staff and visitors. All staff present were observed wearing masks. All bathrooms were inspected and observed supplied with hygiene products and with hand washing signs posted. Bedrooms, kitchen, dining room, living room, and the outside grounds of the facility were inspected. All fire exit routes were and clear of obstructions. Medications were observed in a locked room accessible only to staff. Facility also observed to have adequate supply of Personal Protective Equipment (PPEs).

LPA reviewed the facility COVID-19 related infection control policies and procedures with ADM including screening, social distancing, surveillance testing, disinfecting, staffing, training, isolation, PPE use and inventory.

Updated copies of the following documents were requested from ADM:
1. LIC 500, Personnel Summary
2. LIC 308, Designation of Administrative Responsibility
3. LIC400, Affidavit Regarding Client/Resident Cash Resources
4. LIC610, Emergency Disaster Plan.
5. Current Administrator's Certificate.

No deficiencies issued per Title 22 of the California Code of Regulations. LPA reviewed report with, and a copy provided to Rosa Sanchez.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2021
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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