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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202498
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:13:07 PM

Document Has Been Signed on 01/29/2025 01:13 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 INCFACILITY NUMBER:
435202498
ADMINISTRATOR/
DIRECTOR:		HERRERA, NAYARITHFACILITY TYPE:
735
ADDRESS:805 CAMBRIAN DRTELEPHONE:
(408) 727-3411
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:53 PM
MET WITH:Staff (S2), Tonga Chapman TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On January 29, 2025 at 12:53 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 Staff (S2), Tonga Chapman. LPAs observed one staff member and two residents during the visit. Three out of five residents are in day program.

LPAs spoke on the phone at 11:55 PM with Naya Herrera, Administrator (ADM) and stated the purpose of today's visit. ADM was unable to meet with LPAs during today's visit and verbally gave permission for staff (S2) to sign today's report on her behalf.

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. LPAs sealed the letter and handed it to S2 with ADM's verbal permission. ADM states S1 was never hired, does not work for the facility, is not in their Human Resources (HR) system. Program Manager Felicia Lehner stated she will separate S1 from the facility roster and Guardian.

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

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

This report was reviewed with Staff (S2), Tonga Chapman 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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