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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202786
Report Date: 04/06/2022
Date Signed: 04/06/2022 01:37:56 PM

Document Has Been Signed on 04/06/2022 01:37 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:LEARNING SERVICES CORPORATION - MESA HOUSEFACILITY NUMBER:
435202786
ADMINISTRATOR:SHREEVE, KAYREEFACILITY TYPE:
735
ADDRESS:5672 MESA ROADTELEPHONE:
(408) 848-4379
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 4CENSUS: 0DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Abraham LongoriaTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual required 1-year inspection to focus on inspection control. LPA met with Administrator, Abraham Longoria.

There are currently no residents and staff living in the facility. Residents has been transferred to Learning Service Corporation South Valley Ranch #1 and South Valley Ranch #2 due to the low census since November 2021. Facility remains open and will be used when needed.

During visit, LPA toured the facility to include kitchen, dining room, living room, resident rooms, bathrooms, and garage. Facility has a mitigation plan in place once residents return to the facility.

The following policies and procedures were reviewed to include screening, isolation, cleaning/disinfecting, training, PPE supplies, N95 fit testing, and postings.

LPA informed Administrator to submit Infection Control Plan to CCLD by 06/30/2022 and review PIN 22-13-ASC.

No citations were issued per the California Code of Regulations, Title 22.

This report was reviewing with Abraham Longoria and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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