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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202735
Report Date: 12/15/2021
Date Signed: 12/15/2021 12:44:42 PM

Document Has Been Signed on 12/15/2021 12:44 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 TAMARACK HOMEFACILITY NUMBER:
435202735
ADMINISTRATOR:GOSS, SHELLYFACILITY TYPE:
735
ADDRESS:879 TAMARACK AVETELEPHONE:
(408) 727-3493
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:GOSS, SHELLYTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator, Shelly Goss.

During today's visit, LPA toured the facility inside and outside to include entry way, living room, kitchen, dining room, 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. The following posters were observed to include, social distancing, visitor policy, symptoms of COVID, prevent the spread, and hand washing. Bathrooms have supplies of paper towels, and soap available for staff, residents, and visitors. Dining room chairs were spaced apart to allow for social distancing. LPA observed each resident to have an grab and go folder that contains their emergency contact information. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces multiple times daily and as needed. Staff observed to be wearing a mask.

LPA obtained facilities mitigation plan during visit.

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

This report was reviewed with Shelly Goss and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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