435202627-3-27-2025-26-AS-CKAI-DF6VVK-20250327164627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202627
Report Date: 03/27/2025
Date Signed: 03/27/2025 04:46:40 PM

Document Has Been Signed on 03/27/2025 04:46 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 INC		FACILITY NUMBER:	435202627
ADMINISTRATOR/ DIRECTOR:	TSION HAILE		FACILITY TYPE:	735
ADDRESS:	1521 RAMITA CT		TELEPHONE:	(408) 727-3411
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 5		CENSUS: 5	DATE:	03/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Justin Williams		TIME VISIT/ INSPECTION COMPLETED:	04:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Staff Training and Development (Designated Administrator), Justin Williams. During visit, LPA toured the facility with staff to include the living room, kitchen, 4 resident bedrooms, bathrooms, garage, shed, and backyard. All fire exit routes were free and clear of obstruction. LPA observed the shed is used to store storage items. All staff present were fingerprint cleared and associated to the facility. Facility temperature maintained at 69 degrees F. Fire extinguishers last serviced on 10/28/2024. Carbon monoxide detector observed operable. Sharp objects, chemicals, and medications observed locked. Refrigerator temperature maintained at 43 degrees F. Freezer temperature maintained at 0 degrees F. Items inside the refrigerator observed covered and labeled. Resident bedrooms equipped with beds, linens, dressers, night stands and adequate lighting. The bedroom exit doors are equipped with door alarms. Bathroom is supplied with hygiene supplies and paper supplies. The hot water temperature was measured in the bathroom and observed at 132.8 degrees F. During visit, staff adjusted the hot water temperature and the hot water temperature was measured at 102.7 degrees F. Staff was advised of Title 22 regulations to ensure the water is between 105 - 120 degrees F. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 03/27/2025

NARRATIVE

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Facility has emergency lighting and a bin filled with emergency supplies. Emergency disaster drills are completed quarterly and the last drills was completed on February 2025. Facility has a complete first aid kit.

3 resident records were reviewed. 1 out of 3 residents IPP was from year 2022 and expired in 2023. 3 out of 3 resident records observed complete to include the admission agreement, medical assessment, TB result, personal rights, safeguard of personal properties and valuables form, and consent form. 2 out of 3 resident's had P&I money which was reviewed with staff and all money was accounted for.

3 out of 3 resident medications and centrally stored medication records were inspected. The facility did not have the 3 resident's current centrally stored medication record for February - March 2025.

3 staff records were reviewed and observed complete. 3 staff has an active first aid certification, health screening, TB result, fingerprint clearance and annual training.

Documents were requested by 04/04/2025 to include: LIC309, LIC500, LIC400, Surety Bond, LIC200 (update email address on file and any other information that requires an update), and LIC610D.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Staff Training and Development (Designated Administrator), Justin Williams and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2025 04:46 PM - It Cannot Be Edited

Created By: Christine Kabariti On 03/27/2025 at 04:17 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: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(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
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above wherein the facility's hot water temperature was initially measured at 132.8 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2025
	Plan of Correction
1 2 3 4	Licensee will adjust the hot water temperature and submit a picture of the hot water temperature. Licensee will also train the staff regarding the section cited above. Licensee will submit the picture of the hot water temperature and training record to LPA Kabariti via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2025 04:46 PM - It Cannot Be Edited

Created By: Christine Kabariti On 03/27/2025 at 04:18 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: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80068.2(b)(1)

(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review and observation the licensee did not comply with the section cited wherein 1 out of 3 resident records reviewed did not have an updated IPP and appraisal/needs and services plan which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Licensee will submit a statement of understanding of the section cited above to ensure all resident's appraisal/needs and services or IPP is up-to-date to LPA Kabariti via email by POC due date.

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
1 2 3 4	Based on interview, record review and observation the licensee did not comply with the section cited wherein the facility did not maintain a record of 3 residents current centrally stored medication record which poses a potential health, safety, and personal rights risk to persons in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Licensee will conduct training with staff regarding the maintence of the centrally stored medication record. Licensee will submit the training record to LPA Kabariti via email 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.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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