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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202331
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:10:43 PM

Document Has Been Signed on 11/13/2024 03:10 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:SVS GILROY ADULT DAY PROGRAMFACILITY NUMBER:
435202331
ADMINISTRATOR/
DIRECTOR:		ALISON NOBLEFACILITY TYPE:
775
ADDRESS:7101 MONTEREY ROADTELEPHONE:
(408) 843-9630
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 60CENSUS: 50DATE:
11/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Michele PagsisihanTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Program Director (PD), Michele Pagsisihan.

On 11/04/2024 and 11/08/2024, the Department received 2 incident reports for client (C1) regarding a choking incident. On 11/04/2024 and 11/08/2024, C1 was eating lunch when C1 suddenly started choking on a chicken nugget. On 11/04/2024, staff patted C1's back several times until C1 eventually coughed out the chicken nugget. On 11/08/2024, staff performed the Heimlich Maneuver on C1 to dislodge the food from his/her throat and C1 was able to spit the food out. Staff cut the rest of C1's nuggets and other food items to assure C1 ate without a problem.

During visit, LPA interviewed 2 staff members. Based on staff interview and record review, C1 does not have a special diet from the physician. Staff states that C1's lunch is made and provided by his/her care home. After each choking incident, staff wrote the special incident report (SIR) and provided the SIR to C1's care home staff. It was stated that the staff has had several conversations with C1's care home regarding the food that is being brought to day program for the clients. The SIRs were also reported to the Department and the San Andreas Regional Center.

After the incident on 11/08/2024, staff are now chopping C1's food and ensuring C1 is closely supervised during lunch time. LPA advised the Program Director to meet with C1's care home and authorized representative to update C1's appraisal/needs and service plan to include C1's history on choking on food and a plan for the day program staff to follow to ensure C1's safety, ASAP. See LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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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: SVS GILROY ADULT DAY PROGRAM
FACILITY NUMBER: 435202331
VISIT DATE: 11/13/2024
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LPA advised PD to follow-up with C1's care home and/or physician to possibly update C1's physician's report due to C1's tendency of choking on certain food.

Documents were obtained to include C1's face sheet, physician's report, IPP (Individual Program Plan), ISP (Individual Service Plan), 2 incident reports, and email correspondence.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Director, Michele Pagsisihan and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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