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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201681
Report Date: 10/18/2022
Date Signed: 10/18/2022 04:55:19 PM

Document Has Been Signed on 10/18/2022 04:55 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:LSA - HOME #2FACILITY NUMBER:
435201681
ADMINISTRATOR:TSION HAILEFACILITY TYPE:
735
ADDRESS:830 AGNEW RDTELEPHONE:
(408) 988-9099
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 6CENSUS: 5DATE:
10/18/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Cheryl LagunillaTIME COMPLETED:
05:15 PM
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Licensing Program Analysts (LPA) David Marrufo and Simranjit Rai conducted an unannounced Case Management visit. The visit was in response to an incident that was self-reported by the facility on 10/14/2022 regarding staff discovering that the Personal and Incidental Money of 4 out of 5 residents had gone missing. LPAs also conducted the quarterly non-compliance visit at the same time.

During visit, LPAs interviewed Administrator Cheryl Lagunilla and staff S1-S2. LPAs had staff S1 review the P&I logs for residents R1-R5 during visit. LPAs obtained copies of the following documents for R1-R5: Emergency Contact Forms, Resident Roster, SARC Schedule, and Personal and Incidental Monies Log for September and October 2022. LPAs also obtained copies of the facility visitor's log for October, Staff Roster and Schedule for September and October 2022, and Staff Memo regarding incident of Personal & Incidental Monies Log.

LPAs request Administrator Cheryl Lagunilla to submit a plan to CCL stating how the facility plans to safeguard the Personal and Incidental Money of the residents within 3 business days.

During visit, LPAs conducted staff interviews regarding the following items that were part of the facility's non-compliance plan from 07/21/2021:

(1) Licensee shall develop a plan in writing describing the facility staff training plan for observation, care and supervision of residents.
(2) Licensee shall develop a plan in writing describing the facility staff training plan concerning assessment of residents for any changes in physical, mental, emotional and social functioning and for staff to address the resident's needs such as seeking timely medical attention.

See LIC809-C for more information. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: LSA - HOME #2
FACILITY NUMBER: 435201681
VISIT DATE: 10/18/2022
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(3) Licensee shall develop a plan in writing describing the facility protocol for seeking medical attention and response time to address the resident's needs including identifying symptoms and when to call 911.
(4) Licensee shall develop a plan in writing describing the facility protocol in observing the residents, assessment of residents, completing reappraisals, and developing resident needs and services plan to address the resident's needs.

Administrator agrees to conduct training for the items 1-4 mentioned above and submit training logs to CCLD within 5 business days.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Cheryl Lagunilla and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2