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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202627
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:42:51 PM

Document Has Been Signed on 11/30/2023 01:42 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:TSION HAILEFACILITY TYPE:
735
ADDRESS:1521 RAMITA CTTELEPHONE:
(408) 727-3411
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: DATE:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Tsion HaileTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit regarding an incident report that occurred on 10/01/2023. LPA met with Administrator, Tsion Haile.

It was reported on 10/01/2023, staff noticed resident (R1) was missing a bubble pack of medication upon intended administration of R1’s medication. On 10/01/2023, R1 missed a medication due to the missing bubble pack of medication. Based on interview with the Administrator, it was stated that on the afternoon of Friday, 09/29/2023 the pharmacy delivered the residents monthly medications for October. The delivered medications were not checked until 10/01/2023 because the weekend NOC shift staff are not trained on checking medications. ADM was unable to provide an explanation to why the residents medications were not checked on the PM shift of 09/29/2023, AM shift of 09/30/2023, and PM shift of 09/30/2023. ADM stated they had a new NOC shift staff who is not trained on checking for medications. ADM did not schedule a trained staff during NOC the shift to check the medications nor develop a plan to ensure the residents October medications were checked timely to avoid R1 missing a medication. The staff were not provided with a procedure on calling the pharmacy after hours to provide the medication. R1's doctor and responsible party was informed. R1 did not have any adverse reaction from this incident.

On 10/04/2023, the facility trained all the staff on checking all medications that are delivered to the facility. The facility plans to triple check the delivered medications with the day staff, Administrator, and NOC shift staff. Facility staff were also informed to contact the Administrator during the weekends should there be any issues regarding residents medications. Facility staff were provided training and contact information for the pharmacies when there are any discrepancies and missing medications. Facility has a plan to contact another staff member when the Administrator is out of office. During visit, LPA obtained the training records and facility's procedures to checking new medications upon arrival from the pharmacy.

No deficiency were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Tsion Haile and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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