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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707864
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:01:47 PM

Document Has Been Signed on 10/06/2021 01:01 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-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: 9DATE:
10/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:
Rosa Sanchez		TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced case management visit. This case management visit was regarding an elopement incident on 9/5/2021 involving client (C1). LPAs met with Administrator (ADM), Rosa Sanchez.

On 9/5/2021 around 4:00pm, C1 had left the facility without authorization and returned around 6:00pm. C1 did not notify staff upon his departure and upon his return. On 9/8/2021, C1 had a scheduled doctor’s appointment and a random drug test screening was conducted. On 9/15/2021, facility received notification of a positive drug test result. ADM spoke with C1, wherein C1 admitted of leaving the facility without authorization and purchasing drugs. The facility was not aware of the elopement until the notification of the positive drug test results.

On 9/17/2021, LPA Dolores spoke to ADM via telephone and ADM stated staff did not conduct 30-minute routine checks according to the program plan.

On 10/6/2021, LPAs interviewed C1. C1 confirmed the facts of the incident.

LPAs reviewed C1's physician's report and appraisal/needs and services plan. C1's physician's report stated that C1 is not able to leave the facility unassisted. Facility records review noted 2 staff on duty were given disciplinary actions for failing to conduct 30-minute checks.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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#2
FACILITY NUMBER: 430707864
VISIT DATE: 10/06/2021
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ADM conducted staff training on facility policy and procedures with regard to client 30-minute checks and importance of documentation, sign-in and sign-out procedures, notifying case managers upon resident return from outings, and staff shift hand-offs. ADM will oversee client 30-minute check to ensure staff are following facility procedures.

A Technical Advisory was issued. See attached LIC9102. No citations were issued per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Rosa Sanchez and copy of this report was provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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