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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202627
Report Date: 09/22/2023
Date Signed: 09/22/2023 09:50:44 AM

Document Has Been Signed on 09/22/2023 09:50 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
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: 5DATE:
09/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tsion HaileTIME COMPLETED:
09:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Administrator, Tsion Haile.

On 08/09/2023, the Department received an incident report regarding a missed medication for resident (R1) on 08/08/2023. The missed medication was found the morning on 08/09/2023 by staff. The missed medication is a routine medication that is used to prevent a medical condition. ADM states R1 is doing well. Family was informed and ADM stated the family communicated with R1's physician regarding the medication error.

Based on interview, it was stated that the staff (S1) who had administered the medication was not fully trained nor signed off to be administering medications on their own. The Administrator (ADM) states, S1 had administered medications that morning to help staff (S2) who was assisting residents with hygiene needs. ADM states the facility has a policy to have two people assist with medications for the second person to act as witness.

After the incident on 08/09/2023, the facility had S1 complete training on medication administration the same day, 08/09/2023. Based on record review, the facility last provided training on medication administration on 06/02/2023, to include S2.

During visit, LPA observed the facility completed medication administration training with all staff on 08/15/2023.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. 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: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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 09/22/2023 09:50 AM - It Cannot Be Edited


Created By: Christine Dolores On 09/22/2023 at 09:40 AM
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: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2023
Section Cited
CCR
80065(f)(4)

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(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered. This requirement was not met as evidenced by:
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Licensee has corrected the deficiency prior to visit. Administrator will email proof of medication training to LPA Dolores before end of day 09/22/2023.
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Based on interview, record review, and observation the licensee did not ensure staff (S1) was fully trained to administer medications to administering resident (R1) medications resulting in R1 missing a medication which poses an immediate health, safety, and personal rights risk 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: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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