<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202019
Report Date: 01/26/2024
Date Signed: 01/27/2024 12:01:48 PM

Document Has Been Signed on 01/27/2024 12:01 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LIFE SERVICES ALTERNATIVES INC - MILTONFACILITY NUMBER:
435202019
ADMINISTRATOR:LANSANA, JOSEPHFACILITY TYPE:
734
ADDRESS:441 N MILTON AVETELEPHONE:
(408) 963-6755
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 4DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:JOSEPH LANSANATIME COMPLETED:
12:08 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit today and met with Administrator (ADM) Joseph Lansana. LPA observed 3 staff (S1 - S3) and 4 residents (R1 - R4) in the facility.

LPA reviewed 3 resident files (R1 - R3) and 3 staff files (S1 - S3).

LPA toured the facility with ADM and staff S1. License, personal rights posters, and Administrator Certificate were observed in the main entrance. Living room, dining room, laundry room, garage and kitchen were inspected. 5 resident bedrooms, 2 bathrooms were inspected.

Two days perishable foods and seven day non perishable foods were observed sufficient. Room temperature was observed at 73 degree F, hot water temperature was observed at 105 degree F. Medication cabinet, Knife closet, and cleaning products closet were observed locked. Fire extinguisher was serviced on 7/27/2023. The facility was equipped with fire alarm system and carbon monoxide detectors. Smoke detector alarm system were tested, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

First aid box, flash lights were observed in the facility. ADM stated the facility conducted the emergency drill on 1/05/2024.

Deficiency was noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/27/2024 12:01 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 01/26/2024 at 12:22 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 - MILTON
FACILITY NUMBER: 435202019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, and record review, the licensee did not comply with the section cited above in that 1 out 3 staff did not have LIC503 staff health screening form, which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to have LIC503 staff health screening form completed for staff.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2