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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707864
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:04:31 PM

Document Has Been Signed on 06/20/2024 04:04 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
Lookup Error,
, CA
FACILITY NAME:LEARNING SERVICES-SOUTH VALLEY RANCH#2FACILITY NUMBER:
430707864
ADMINISTRATOR/
DIRECTOR:
SHREEVE, KAYREEFACILITY TYPE:
735
ADDRESS:10855 DE BRUIN WAYTELEPHONE:
(408) 848-4379
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 10CENSUS: 9DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Abraham LongoriaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 6/20/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator/Program Director Abraham Longoria. LPA explained the purpose of the visit.

Facility is serving residents with traumatic brain injury. LPA toured the facility including some resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. Resident rooms have all personal belongings intact. While touring the facility it was observed that the room temperature was at 72 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Facility has a sprinkler system. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every month.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA received the following documents: Administrator Certificate. Administrator will be sending the LIC500, LIC400 & Lease Agreement.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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