<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201914
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:43:45 AM

Document Has Been Signed on 06/14/2024 11:43 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LIFE SERVICES ALTERNATIVES INC - SB 962 HOME #1FACILITY NUMBER:
435201914
ADMINISTRATOR/
DIRECTOR:		LANSANA, JOSEPHFACILITY TYPE:
734
ADDRESS:1320 S BAYWOOD AVETELEPHONE:
(408) 982-5625
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 4DATE:
06/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Joseph LansanaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Administrator, Joseph Lansana.

The purpose of the visit is to follow-up on a report the Department received from a semi-annual review from the Department of Developmental Services (DDS).

On 05/22/2024, the facility had a semi-annual review with DDS. During the review, it was observed that resident (R1) was being served lunch and staff did not follow the specific feeding instructions, per R1's physician's order.

During visit, LPA interviewed 2 staff members. Based on interview, the staff stated that R1's food mixture was stewing for a longer period, which resulted in the consistency being pudding-thick rather than honey-thick. Staff (S2) admitted that the incident did occur but knew that R1 should have been fed a honey-liquid consistency mixture. S2 states he/she was provided training after the incident. Going forward, S2 states he/she is more careful about ensuring R1 is being fed the right liquid consistency.

LPA obtained R1's physician's report, physician's order, and training documentation. The review of records show that staff were provided training on R1's liquid consistency mixture and feeding and liquid presentation. Staff were also provided a training video regarding liquid consistency mixtures.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Joseph Lansana and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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
Document Has Been Signed on 06/14/2024 11:43 AM - It Cannot Be Edited


Created By: Christine Dolores On 06/14/2024 at 11:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIFE SERVICES ALTERNATIVES INC - SB 962 HOME #1
FACILITY NUMBER: 435201914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2024
Section Cited
CCR
80065(a)

1
2
3
4
5
6
7
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee has provided training to staff regarding resident (R1)'s liquid consistency and feeding and liquids presentation. Deficiency was cleared during visit.
8
9
10
11
12
13
14
Based on interview, record review, and observation the licensee did not ensure staff (S2) was competent to provide the services necessary to meet a resident's feeding needs which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2