<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202733
Report Date: 12/14/2021
Date Signed: 12/14/2021 12:31:07 PM

Document Has Been Signed on 12/14/2021 12:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LIFE SERVICES ALTERNATIVES CALLE VIENTO HOMEFACILITY NUMBER:
435202733
ADMINISTRATOR:VICENTE, ROGELIOFACILITY TYPE:
735
ADDRESS:545 CALLE VIENTOTELEPHONE:
(408) 727-3493
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 4DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Mayclaire CabacunganTIME COMPLETED:
12:35 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 Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Caregiver, Mayclaire Cabacungan.

During today's visit LPA observed 2 residents socially distanced in the kitchen table. LPA toured the facility inside and outside to include entry way, living room, TV room, kitchen resident rooms, bathrooms, and backyard. Fire exits were free and clear of obstruction.

LPA observed a central entry point, screening area, and hand sanitizer for all visitors, residents, and staff. LPA observed the following posters, feeling ill, social distancing, visitor policy, and hand washing. LPA observed the bathroom to have supplies of paper towels, and soap available for staff, residents, and visitors. Trash cans were observed covered with lid. LPA observed each resident to have an emergency bag located in the garage. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces multiple times daily and as needed.

LPA advised to add more symptoms to the screening questionnaire to include fatigue, muscle body aches, headache, loss of taste or smell, congestion, runny nose, nausea, vomiting, and diarrhea.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Note provided.

This report was reviewed with caregiver, Mayclaire Cabacungan and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1