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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202735
Report Date: 12/15/2022
Date Signed: 12/15/2022 04:15:57 PM

Document Has Been Signed on 12/15/2022 04:15 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 TAMARACK HOMEFACILITY NUMBER:
435202735
ADMINISTRATOR:GOSS, SHELLYFACILITY TYPE:
735
ADDRESS:879 TAMARACK AVETELEPHONE:
(408) 727-3493
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 5DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Shelly GossTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Shelly Goss.

During visit, LPA toured the facility to include the living room, bedrooms, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff observed wearing a face covering.

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

The following document was requested to include the LIC610D.

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

This report was reviewed with Administrator, Shelly Goss and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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