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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202627
Report Date: 03/09/2022
Date Signed: 03/11/2022 10:21:44 AM

Document Has Been Signed on 03/11/2022 10:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LIFE SERVICES ALTERNATIVES INCFACILITY NUMBER:
435202627
ADMINISTRATOR:GOSS, SHELLYFACILITY TYPE:
735
ADDRESS:1521 RAMITA CTTELEPHONE:
(408) 727-3411
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 5DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Justin WilliamsTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator, Justin Williams.

During today's visit, LPA toured the facility inside and outside to include entry way, living room, kitchen, dining room, resident rooms, bathrooms, and backyard. Fire exits were free and clear of obstruction. All staff observed to be wearing a mask.

LPA observed a central entry point, screening area, and hand sanitizer for all visitors, residents, and staff. The following posters were observed to include social distancing, symptoms of COVID, hand washing, and required masks. Bathrooms have supplies of paper towels, and soap available for staff, residents, and visitors. Facility is working on providing N95 fit testing for staff.

Facility has a sufficient amount of PPE supplies. LPA advised facility to disinfect and sanitize high touch surfaces multiple times daily and as needed.

LPA obtained facility's mitigation plan during visit. LPA will provide Administrator with COVID-19 posters.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Justin Williams and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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