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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202627
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:10:12 PM

Document Has Been Signed on 04/18/2023 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:LIFE SERVICES ALTERNATIVES INCFACILITY NUMBER:
435202627
ADMINISTRATOR:JUSTIN WILLIAMSFACILITY TYPE:
735
ADDRESS:1521 RAMITA CTTELEPHONE:
(408) 727-3411
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 0DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Felicia LehnerTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to conduct the facility's annual inspection. LPAs met with Program Manager (PM), Felicia Lehner.

During visit, LPAs toured the facility to include the living room, kitchen, resident bedrooms, bathrooms, garage, and backyard. All fire exits and passageways are free and clear of obstruction. Fire extinguisher last serviced on 09/27/2022. Facility has an operable carbon monoxide detector. Facility's temperature maintained at 72 degrees Fahrenheit. Resident bedrooms furnished with beds, clean linens, dressers, night stands, and adequate lighting. Bathrooms supplied with hygiene products and hand washing sign. Facility has adequate amount of linens and towels.

LPAs observed 2 knives on the kitchen's drying rack. Staff (S1) immediately secured the knives in a locked drawer. One resident who required one-to-one supervision was present during part of the visit. Staff (S1) state the knives were drying and the resident present is always being supervised. LPAs observed at least 2 days worth of perishables and 7 days worth of non-perishables foods. Refrigerator temperature maintained at 41 degrees Fahrenheit. Freezer temperature observed at 4 degrees Fahrenheit. During visit, staff adjusted the freezer temperature to 0 degrees Fahrenheit. Hot water temperature in the kitchen maintained at 138.7 degrees Fahrenheit. During visit, staff adjusted the hot water meter. LPAs observed the hot water temperature at 120 degrees Fahrenheit. Facility was informed the hot water temperature should not be more than 120 degrees Fahrenheit. Kitchen equipped with a lidded trash bin.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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: LIFE SERVICES ALTERNATIVES INC
FACILITY NUMBER: 435202627
VISIT DATE: 04/18/2023
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LPAs reviewed 4 resident files to include their admission agreement, physician's report, needs and services plan, emergency information, personal rights, safeguard of personal property, consent forms, safeguard of cash resources, and centrally stored medication records. LPAs observed 4 out of 4 residents centrally stored medications were not being maintained with current medications. Facility was advised. LPAs observed 2 out of 3 residents cash resources were both missing $20. Facility was advised.

LPAs reviewed 3 staff files to include their 1st aid certification, health screening report, employee rights, criminal record clearance, LIC501, and training records. LPAs observed all staff have not been provided recent training on medication. PM states the staff were scheduled to attend medication training on 04/07/2023, however, was unable to locate the training sign-in sheet due to the facility Administrator being out on vacation. Facility was advised. LPAs observed the facility has a monthly schedule posted for emergency and fire drill training. LPAs observed the last emergency and fire drill training conducted was in December 2022. Facility was advised.

LPAs observed the facility's first aid kit. Facility has a ready to go emergency bin. Facility has red folders located near the facility's entrance that includes all resident's emergency and medical information.

Signs and posters observed to include personal rights, house rules, rights of resident councils, if you see something say something, and emergency contacts.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Program Manager, Felicia Lehner and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2023 03:10 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/18/2023 at 02:08 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: 435202627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes 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 ensure all current centrally stored medications were maintained in the centrally stored medication record which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 04/25/2023
Plan of Correction
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Licensee will conduct a medication training. Licensee submit their plan and training record to ensure all centrally stored medications are being properly recorded in the centrally stored medication record. Licensee will submit their POC to LPA Dolores by POC due date.
Type B
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility's hot water temperature was maintained at 138.7 degrees F which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 04/25/2023
Plan of Correction
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Licensee immediately adjusted the hot water temperature. Licensee will submit their staff training plan to ensure the hot water temperature is attained between 105 and not more than 120 degrees F. Licensee will submit their POC to LPA Dolores by POC due date.
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: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
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