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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201914
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:50:05 AM

Document Has Been Signed on 11/19/2021 11:50 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:LIFE SERVICES ALTERNATIVES INC - SB 962 HOME #1FACILITY NUMBER:
435201914
ADMINISTRATOR:LANSANA, JOSEPHFACILITY TYPE:
734
ADDRESS:1320 S BAYWOOD AVETELEPHONE:
(408) 982-5625
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 5DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:LANSANA, JOSEPH TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator Joseph Lansana and Lead Staff Victoria Oyewole.

During today's visit LPA observed 5 residents socially distanced in the living room watching a day program activity. LPA toured the facility inside and outside to include kitchen, living room, garage, hallways, resident rooms, bathrooms, and backyard. Fire exits were free and clear of obstruction.

LPA observed a central entry point, screening area, and hand sanitizer for all visitors and staff. LPA observed the following posters, symptom reporting, social distancing, staff sick leave policy, minimize the spread, and hand washing. LPA observed the bathroom to have supplies of paper towels, and soap available for staff, residents, and visitors. Trash cans were observed covered with lid inside each resident room. LPA observed each resident to have an emergency bag located in their closet. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces multiple times daily and as needed.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Administrator Joseph Lansana and Lead Staff Victoria Oyewole. Copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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