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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202017
Report Date: 12/12/2022
Date Signed: 12/12/2022 04:23:27 PM

Document Has Been Signed on 12/12/2022 04:23 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 - MCKENDRIEFACILITY NUMBER:
435202017
ADMINISTRATOR:DUGUMA, JEMANESH (JEMA)FACILITY TYPE:
734
ADDRESS:895 MCKENDRIE STTELEPHONE:
(408) 216-0143
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 5CENSUS: 5DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Jemaneh (Jema) DugumaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Jemanesh (Jema) Duguma.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a visitor screening area at the entrance. LPA Marrufo observed a 30-day supply of PPEs, a 2-day supply of perishable food, and 7 day supply of non-perishable food. LPA Marrufo observed the facility bathrooms to have hand washing signs, soap, and paper towels. The outdoor area exits were free of obstructions.

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

This report was reviewed with Administrator Jemanesh (Jema) Duguma and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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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