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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202019
Report Date: 01/21/2025
Date Signed: 01/21/2025 05:13:03 PM

Document Has Been Signed on 01/21/2025 05:13 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 - MILTONFACILITY NUMBER:
435202019
ADMINISTRATOR/
DIRECTOR:		LANSANA, JOSEPHFACILITY TYPE:
734
ADDRESS:441 N MILTON AVETELEPHONE:
(408) 963-6755
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 5DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Administrator Joseph LansanaTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator Joseph Lansana. LPA toured the interior and exterior of the facility with ADM to include the kitchen, office, resident rooms, dining room, bathrooms, back and front of the facility. Facility thermostat temperature display was observed at 72 degrees F. All exit and passageways were free and clear of obstruction.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care.

The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were last inspected on 1/2/2025. Fire extinguishers were last serviced on 6/26/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 1/6/2025. Drills are being conducted quarterly.

LPA toured 5 resident bedrooms. 5 out of 5 resident bedrooms have a bed, functioning lights, dresser/table, a chair, bedding and space for personal belongings. LPA toured 1 resident bathroom. 1 out of 1 bathroom had hand soap, paper towel, functioning lights, and covered trash bins. LPA measured water temperature at 133.1 degrees F. LPA advised ADM to have the water temperature adjusted to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

See LIC809C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - MILTON
FACILITY NUMBER: 435202019
VISIT DATE: 01/21/2025
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LPA reviewed 5 resident records. 5 out of 5 resident records were found to be complete. Resident records included emergency contact information, physician’s report, appraisal/needs and service plans, and personal rights.

LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). 4 out of 5 CSMDR’s were observed to be complete with all medication documented. LPA observed Resident R3 did not have a CSMDR for 8 prescription medications. ADM stated the CSMDR was created but could not find R3's CSMDR for the 8 prescription medications. LPA advised ADM to document the 8 prescriptions on a CSMDR form for R3. R3 has a CSMDR completed during visit.

LPA reviewed 4 residents P&I with ADM. 4 out of 4 residents P&I were observed to be documented accurately with all money accounted.

LPAs reviewed 4 staff records. 4 out of 4 staff records were found to be complete. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record and staff training.

Deficiencies were cited during today’s visit per California Code of Regulations Title 22. See LIC809-D. An exit interview was conducted with ADM Joseph Lansana. A signed copy of this report and appeal rights were provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2025 05:13 PM - It Cannot Be Edited


Created By: Marcella Tarin On 01/21/2025 at 04:54 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA measured water temperature in resident bathroom at 133.1 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.


Based on observation, the licensee did not comply with the section cited above. LPA measured water temperature at 133.1 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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ADM states he will have the water temperature adjusted on 1/22/2025, and submit proof of repair for the water temperature. Licensee will submit documentation to CCL by POC due date 1/22/2025.
Type A
Section Cited
CCR
80075(7)(A-G)
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D)The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Expiration date. (G) Number of refills.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed Resident R3 did not have a CSMDR for 8 prescription medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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During visit ADM documented R3s 8 prescription medication on a CSMDR. ADM will conduct in-staff training by 1/22/2025 on health related services, and provide documentation of training to CCL by POC due date 1/22/2025.
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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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