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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201914
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:41:29 PM

Document Has Been Signed on 10/28/2024 04:41 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: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:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Joseph LansanaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator, Joseph Lansana.

During visit, LPA toured the facility with staff to include the living room, kitchen, resident bedrooms, bathrooms, garage, and exterior. All fire exit routes are free and clear of obstruction. Upon arrival, 3 staff observed present to include 1 LVN and 2 DSPs. At 2:30PM, shift change occurred and LPA observed 3 staff present to include 2 LVNs and 1 DSP. All staff present are fingerprint cleared and associated to the facility.

Facility temperature maintained between 69 - 71 degrees F. Refrigerator contains food items that are covered and labeled. Kitchen equipped with locked sharp objects, chemicals and disinfectants. Medications inside the refrigerator contains a lock. Carbon monoxide detectors observed in the hallways near the resident bedrooms. Fire extinguisher last served on 06/26/2024. Oxygen in use sign posted on the doors of every resident bedrooms. Resident bedrooms equipped with beds, linens, adequate lighting, and personal items. Each resident has a grab and go backpack located in their closet. Bathroom equipped with a shower bed, hygiene supplies, and grab bars. Hot water temperature in the resident bathroom maintained at 115.7 degrees F.

Facility has a portable generator and back-up battery in case of an emergency, which are being tested monthly. The last test was completed on 10/12/2024. Facility has an emergency disaster plan. Facility conducts their emergency drills quarterly, the last drill was completed in October 2024. See LIC809-C for additional information.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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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: LIFE SERVICES ALTERNATIVES INC - SB 962 HOME #1
FACILITY NUMBER: 435201914
VISIT DATE: 10/28/2024
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3 resident files were reviewed and observed them to be complete to include (but not limited to) an up to date IPP. 3 resident's centrally stored medications and centrally stored medication records were reviewed with the LVN. No issues noted during medication review. 3 resident's P&I money was inspected and counted with the ADM. No issues noted during P&I money review.

3 staff files were reviewed and observed them to be complete to include (but not limited to) an up to date 1st Aid Certification and annual training.

The Administrator's ARF Administrator certificate is currently pending by the Department. A copy of the facility's emergency disaster plan (LIC610D) and designation of facility responsibility (LIC308) was obtained during visit.

LPA Dolores requested for the facility's up to date Personnel Report (LIC500).

No deficiencies were cited per California Code of Regulations, Title 22. This repot was reviewed with Administrator, Joseph Lansana and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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