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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202735
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:15:31 PM

Document Has Been Signed on 12/21/2023 02:15 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: DATE:
12/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Shelly GossTIME COMPLETED:
02:20 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 arrived unannounced to conduct a case management - incident visit. LPA met with Administrator, Shelly Goss.

On 11/03/2023, the Department received a report from the facility regarding missing funds for the residents. It was reported by the Administrator that on 11/02/2023 around 11:00am, the Administrator became aware that 4 out of 5 residents (R1 - R4) were each missing $100 from their funds which was kept in a locked safe. Only employees has access to the safe, however, it is unknown who had taken money from each resident. There was no financial impact on the residents. The facility's company replaced the resident's stolen money.

During today's visit, LPA Dolores interviewed the Administrator. Based on interview, only certain staff members had access to the facility's safe. After the incident, the Administrator had talked to each staff member to include the staff members who had access to the safe, in which the staff members denied removing the money. The facility's action plan was to change the safe's code, where only the Administrator and one other staff member has access to. The Administrator informed R1 - R4's family members of the missing funds. The Administrator confirmed that the facility's company replaced the resident's money.

LPA and Administrator reviewed 5 residents P&I money. 5 out of 5 residents P&I money were complete with no deficit of money.

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: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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