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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202017
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:52:03 PM

Document Has Been Signed on 10/25/2023 04:52 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:
10/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Fekadu WelelaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Fekadu Welela. The purpose of the visit was to address deficiencies found during a semi-annual review of the facility on 07/20/2023 by the Department of Developmental Services.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Fekadu Welela and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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Document Has Been Signed on 10/25/2023 04:52 PM - It Cannot Be Edited


Created By: David Marrufo On 10/25/2023 at 04:22 PM
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 - MCKENDRIE
FACILITY NUMBER: 435202017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
80075(a)

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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement
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Licensee agrees to submit a Plan of Correction by POC date to ensure that reisident's first aid and other needed medical and dental services, including availability of spare tracheostomy tubes, are met.
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was not met as evidenced by: Licensee did not ensure that resident R1's physician's order to have tracheostomy tube by R1's bedside was followed, posing an immediate safety risk to residents in care.
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Type A
10/26/2023
Section Cited
CCR80075(e)(2)(E)

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80075 Health Related Services (e) In adult CCFs, when a client requires oxygen the licensee is responsible for the following: (2) Ensuring that the following conditions are met if oxygen equipment is in use: (E) Oxygen tanks that are not portable are secured either in a stand or to the wall.
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Licensee agrees to submit a Plan of Correction by POC date to ensure that oxygen tanks are secuired either in a stand or to the wall.

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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:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
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