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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201914
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:58:59 AM

Document Has Been Signed on 11/22/2022 11:58 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:LANSANA, JOSEPHFACILITY TYPE:
734
ADDRESS:1320 S BAYWOOD AVETELEPHONE:
(408) 982-5625
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 5DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Joseph LansanaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Lead Staff, Victoria Oyewole and Administrator, Joseph Lansana.

During visit, LPA toured the facility to include the kitchen, garage, living room, resident rooms, bathrooms, and backyard. All fire exit routes were free and clear of obstruction.

Facility temperature maintained between 69 degrees - 72 degrees Fahrenheit. LPA observed facility's emergency supply. All staff present are fingerprint cleared and associated to the facility. All staff observed wearing a face mask.

Facility has a designated entry point for symptom screening and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with paper supplies, hygiene products, and hand washing sign. Facility staff clean and disinfect multiple times daily and as needed. Residents temperature and symptoms are documented multiple times daily. Facility staff are trained on infection control and disaster response. LPA observed facility's Personal Protective Equipment (PPE) supplies and lidded trash bin. Staff are N95 fit-tested. LPA reviewed the facility's sick policy and procedures to visitation, isolation, and testing. The following posters observed to include social distancing and hand washing.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Victoria Oyewole and Joseph Lansana and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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