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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202627
Report Date: 08/01/2023
Date Signed: 08/01/2023 04:31:13 PM

Document Has Been Signed on 08/01/2023 04:31 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: 5DATE:
08/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Tsion HaileTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Administrator (ADM) Tsion Haile.

On 07/26/2023 the Department received an incident report for resident (R1). On 07/25/2023 around 10:00am, it was reported by a concerned citizen that R1 was left unattended in the back seat of a vehicle, with the front windows partially down, in full sun, while staff (S1) ran a personal errand.

During visit, LPA interviewed 2 LSA staff members and toured the facility. LPA observed 5 out of 5 residents.

Based on interview, R1 was left in a running car while S1 ran a personal errand using the facility’s company van with the company logo on it. The time R1 was left in the vehicle unattended was unknown. It was not indicated that R1 was exhibiting any behaviors. R1 returned to the facility and was observed with no signs of body injury or changes in behavior. After the incident, the facility conducted an in-service training with staff to include the facility’s policy on resident abandonment. S1 was terminated from the facility.

Documents were obtained to include R1’s IPP, in-service training, and LSA’s resident abandonment policy.

The review of records states R1 requires close supervision and monitoring at-all-times.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with ADM and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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Document Has Been Signed on 08/01/2023 04:31 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/01/2023 at 04:15 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
80078(a)

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(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee corrected the deficinecy prior to visit by conducting an in-service training with staff. POC cleared.
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Based on interview, record review, and observation resident (R1) requires close supervision and monitoring at all times and was left in a vehicle unattended which poses an immediate health, safety, and personal rights to persons in care.
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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: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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