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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202841
Report Date: 10/27/2021
Date Signed: 10/28/2021 03:01:08 PM

Document Has Been Signed on 10/28/2021 03:01 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 HATIKVAH HOUSEFACILITY NUMBER:
435202841
ADMINISTRATOR:FELICIA LEHNERFACILITY TYPE:
735
ADDRESS:577 NORTH CENTRAL AVENUETELEPHONE:
(408) 727-3493
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 6CENSUS: 4DATE:
10/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Felicia LehnerTIME COMPLETED:
03:34 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced pre-licensing inspection today. LPA met with Administrator (Admin) Felicia Lehner. At 10:16am, LPA toured the facility inside and out. Including living room, dining room, kitchen, family room, 6 bedrooms, 5 bathrooms, laundry room, office, and garage. A screening station was observed by the entry door for anyone coming in the facility. Facility staff properly screened LPA before entering the facility.

The facility is equipped with connected smoke detectors. The smoke detector located in the dining room was observed to be working. Fire extinguisher was observed in the dining room and had been last serviced in May of 2021. The kitchen, dining, living room, and family room were observed in good repair. Resident and personnel files observed to contain all necessary documentation, including Individualized Personal Plans, Admissions Agreements, and criminal background clearances.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Bathrooms were observed clean and in working order. The water temperature was measured at 105.1 *F in facility bathroom. Centrally stored medication cabinet was observed. 2 days supply of perishable and 1 weeks supply of nonperishable food observed. A complete first aid kit was inspected.

LPA observed facility fence to have been in disrepair, with many planks of wood laying on the ground. Admin indicated that the fence was blown over by recent storms. Admin coordinated fence repair with corporate office while LPA was at facility.

Component III orientation was waived due to licensee's prior experience. Based on today's inspection, the physical plant is recommended for licensure pending the repair of the broken fence. Exit interview conducted with and copy of report provided to Administrator Felicia Lehner
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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