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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202018
Report Date: 12/15/2022
Date Signed: 12/15/2022 02:55:34 PM

Document Has Been Signed on 12/15/2022 02:55 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 - EMPEYFACILITY NUMBER:
435202018
ADMINISTRATOR:TANCINCO, ARMIEFACILITY TYPE:
734
ADDRESS:649 EMPEY WAYTELEPHONE:
(408) 642-1924
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 5DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Africa GarlejoTIME COMPLETED:
03:00 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 Designee Administrator, Africa Garlego, RN.

During visit, LPA toured the facility to include the resident rooms, bathroom, living room, kitchen, garage, and backyard. All fire exit routes were free and clear of obstruction. All toxins and sharp objects observed secured. Staff observed wearing a face covering. All staff are fingerprint cleared and associated to the facility.

Facility has a designated entry point for sign-in, symptom screening, and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. LPA recommended facility to post their visitation policy and latest PINs on visitation at the main entrance. Bathrooms supplied with paper supplies, hygiene products, and hand washing sign. LPA observed facility's Personal Protective Equipment (PPE) supplies and PPE cart. Facility has procedures to isolation and testing requirements. LPA observed each bedroom to have a donning and doffing poster. LPA recommended facility to have a lidded trash bin located inside each isolation room. Resident's temperatures and symptoms are being monitored and documented every shift and more frequently, when needed. Facility staff clean and disinfect multiple times and as needed. Facility staff are not N95 fit tested. Staff have been provided training on infection control.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Designee Administrator, Africa Garlego, RN and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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