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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202841
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:47:04 PM

Document Has Been Signed on 11/08/2022 02:47 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 HATIKVAH HOUSEFACILITY NUMBER:
435202841
ADMINISTRATOR:JUSTIN WILLIAMSFACILITY TYPE:
735
ADDRESS:577 NORTH CENTRAL AVENUETELEPHONE:
(408) 727-3493
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 6CENSUS: 4DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Justin WilliamsTIME COMPLETED:
02:47 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced pre-licensing inspection today. LPA met with Administrator (Admin) Justin Williams.

LPA toured the facility inside and out, including living room, dining room, kitchen, family room, 6 bedrooms, 4 bathrooms, laundry room, office, and garage. A screening station was observed by the entry door for anyone coming in to the facility. Facility staff properly screened LPA before entering the facility.

All bathrooms noted to have hand-washing signs, lidded trash cans soap and paper towels. Facility temperature noted to be between 68*F. Facility water temperature measured to be within appropriate levels. Fire extinguishers noted to be last inspected in May of 2022. locked medication cabinet was observed. Sharps noted to be locked in designated drawers No prohibited items noted in inspected resident rooms. All emergency exits noted to be clear of obstruction.

Infection Prevention plan already submitted to licensing. Hand sanitizers, soap, and paper supplies were observed available. At least 30 days' supply of personal protective equipment (PPE) were available in the premises. Per Administrator, the facility is currently accepting visitors inside the facility, including residents' bedrooms. The facility has reached a 100% COVID-19 vaccination rate for staff and 100% for residents.

No deficiencies were cited. No advisory notes issued. Exit interview conducted with Administrator Justin Williams and a copy of this report was provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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