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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202498
Report Date: 05/02/2024
Date Signed: 05/02/2024 05:22:09 PM

Document Has Been Signed on 05/02/2024 05:22 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:
435202498
ADMINISTRATOR/
DIRECTOR:		EDWEENA DANIHERFACILITY TYPE:
735
ADDRESS:805 CAMBRIAN DRTELEPHONE:
(408) 727-3411
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 5DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Naya HerrerraTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 year inspection. LPA met with Administrator, Naya Herrerra.

LPA toured the facility to include the resident bedrooms, bathrooms, living rooms, kitchen, garage, office, and backyard. All fire exit routes were free and clear of obstruction. Facility temperature maintained at 70 degrees Fahrenheit. Fire extinguisher last services on 06/27/2023. Facility has a dual smoke detector and carbon monoxide detector. Sharp objects, chemicals, disinfectants, and medications observed secured. Fire place observed screened in the living room. LPA observed the residents coming home from day program and school. Residents observed doing activities and eating snacks.

Resident bedrooms equipped with beds, linens, dressers, and adequate lighting. Bedrooms exit doors that leads to the backyard observed with an auditory device. Bathroom supplied with hygiene products. LPA unable to take the facility hot water temperature due a broken water thermometer. Refrigerator temperature maintained at 40 degrees Fahrenheit. Freezer temperature maintained below 0 degrees Fahrenheit. Kitchen observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator observed covered.

LPA reviewed 3 resident files were maintained to include an admission agreement, medical assessment, TB result, IPP and/or appraisal/needs and services plan, consent form, personal rights, and safeguard of personal property and valuables. LPA reviewed 3 residents centrally stored medications and centrally stored medication records.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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Document Has Been Signed on 05/02/2024 05:22 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/02/2024 at 04:20 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
FACILITY NUMBER: 435202498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80026(h)
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 2 out of 3 counts in which 2 residents were missing P&I money which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will submit a written plan and plan of action to ensure all resident's P&I money are accurate going foward. Licensee will submit the plans to LPA Dolores via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


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
FACILITY NUMBER: 435202498
VISIT DATE: 05/02/2024
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3 out of 3 resident medications observed maintained. 3 out of 3 resident P&I money was counted with the Administrator. LPA observed resident (R1) is missing $10 and resident (R2) is missing $14.76. Administrator was able to provide an explanation to R1's missing P&I money, however, was unable to provide an explanation for R2's missing P&I money. Administrator was advised.

LPA reviewed 3 staff files to include a job application, employee rights, TB result, fingerprint clearance. 3 out of 3 staff present are fingerprint cleared.

Facility's last emergency drill was conducted on 02/12/2024. Facility has emergency lighting available. LPA observed the emergency disaster plan and infection control plan.

Documents were requested to change the Administrator on file to include Administrator Certificate, Board Letter, LIC501, LIC500, LIC9182 or LIC9188, and photo ID. Liability insurance requested by tomorrow, 05/03/2024.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Naya Herrerra and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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