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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202733
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:45:48 PM

Document Has Been Signed on 12/28/2022 02:45 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 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: 0DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Orlando FerrerTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. Administrator, Rogelio Vicente was contacted but did not arrive in time prior to LPA completing the visit. ADM verbally designated Direct Support Staff (DSP) Orlando Ferrer to conduct the visit with LPA.

During visit, LPA toured the facility with DSP to include the living room, kitchen, bedrooms, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction.

Facility has a designated entry point for symptom screening, temperature check, and sign-in. Hand sanitizer made available at entry. Visitation guidelines posted at entry. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. LPA observed facility's Personal Protective Equipment (PPE) supplies. Trash bin with lid observed. Facility staff clean and disinfect multiple times daily and as needed. Facility staff are trained on infection control and are N95 fit tested. Facility has procedures to visitation and isolation. The following COVID-19 posters observed to include social distancing, feeling ill, and required mask.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with DSP, Orlando Ferrer and a copy of the report will be emailed to the Administrator due to printer issues.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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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