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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202735
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:21:27 PM

Document Has Been Signed on 01/29/2025 01:21 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/
DIRECTOR:		GOSS, SHELLYFACILITY TYPE:
735
ADDRESS:879 TAMARACK AVETELEPHONE:
(408) 727-3493
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 5CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Shelly GossTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived at the facility unannounced to conduct a case management – other visit. LPA met with Administrator (ADM) Shelly Goss.

The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical.

S1 was not currently working in the facility. The facility's program manger stated the staff was terminated in 2023.

The immediate exclusion letter was handed to the ADM. The ADM was informed to remove S1 from any contact with clients and not allow S1 to be physically present in the facility. The ADM was advised to separate S1 from the facility roster.

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

This report was reviewed with Shelly Goss and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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