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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202343
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:07:32 PM

Document Has Been Signed on 01/29/2025 04:07 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 INCFACILITY NUMBER:
435202343
ADMINISTRATOR/
DIRECTOR:		CYNTHIA HILLFACILITY TYPE:
735
ADDRESS:455 CYPRESS AVETELEPHONE:
(408) 638-7828
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 5CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Zack Petterson, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On January 29, 2025 at 3:50 PM, Licensing Program Analysts (LPAs) Kenneth Madrigal and Simi Rai arrived at the facility unannounced to conduct a case management – other visit. LPAs met with Zack Petterson (ADM) Administrator and stated the purpose of today's visit. LPAs observed two staff members and two residents during the visit. Three out of five residents are out of the facility during the time of the visit.

The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. Program Manager Felicia Lehner (PM) states S1 was never hired, does not work for the facility, is not in their Human Resources (HR) system. PM stated she will separate S1 from the facility roster and Guardian.

ADM will submit an updated LIC 500 to the Department via email.

During today's visit, LPAs provided the Notice of Community Care Licensing Fees document to Zack Petterson, Administrator which was returned to the Regional Office due to wrong mailing address for the facility. ADM stated to submit a letter to change the mailing address of the facility.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Zack Petterson, Home Administrator and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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