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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202017
Report Date: 09/19/2024
Date Signed: 09/21/2024 03:44:47 PM

Document Has Been Signed on 09/21/2024 03:44 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/
DIRECTOR:		DUGUMA, JEMANESH (JEMA)FACILITY TYPE:
734
ADDRESS:895 MCKENDRIE STTELEPHONE:
(408) 216-0143
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 5CENSUS: 5DATE:
09/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Jemanesh DugumaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Steve Chang and Santino Fortes conducted an unannounced Case Management - Deficiencies visit and met with Administrator (ADM) Jemanesh Duguma.

On 08/22/2024, the Department of Development Services Conducted a semi-annual inspection visit at the facility. The facility was found not in compliance with Title 22 Regulations.

During the inspection. based on the review of a staff nurse (RN) staff file, it was found that no document to show the RN to have valid/current first aid training.

Based on Title 22 Regulations, staff responsible for providing direct care and supervision shall receive training in first aid.

The deficiency was noted during the inspections. Citation was issued today. Please see LIC 809-D. Appeal rights was attached.

Exit interview was conducted with ADM. ADM disagreed the deficiency and citation. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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Document Has Been Signed on 09/21/2024 03:44 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 09/07/2024 at 12:05 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
CCR
80075(f)

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80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
This requirement is not met as evidenced by:
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Administrator stated to submit a plan of correction by the POC due date to ensure the staff responsible for providing direct care and supervision to residents to obtain/receive the first aid training and to be documented in staff file.
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Based on the record review, a staff nurse (RN) did not have current first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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