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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202841
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:06:52 PM

Document Has Been Signed on 10/30/2024 05:06 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/
DIRECTOR:		JUSTIN WILLIAMSFACILITY TYPE:
735
ADDRESS:577 NORTH CENTRAL AVENUETELEPHONE:
(408) 727-3493
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 6CENSUS: 6DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Director Justin WilliamsTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection visit at 2:15PM and met with Director Justin Williams. LPA toured the facility inside and out with the Director to include the resident dining room, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained at 75 degrees F. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 35 degrees F and freezer maintained at -0 degrees F. LPA measured hot water temperature at 106.7. LPA observed medications were in a locked cabinet in the kitchen.

LPA Tarin toured resident bedrooms. 6 out of 6 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, a chair, lamp and dresser/table.

Fire extinguishers were last serviced on 10/28/2024. Facility smoke detectors functioned properly when tested. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 10/7/2024. Facility has emergency disaster plan.

LPA reviewed 6 resident records. LPA observed 6 out of 6 resident records as complete to include a physician's report ,TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms.

See LIC809-C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 435202841
VISIT DATE: 10/30/2024
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LPA reviewed 5 staff records to include fingerprint clearance, health screening, TB result, and personnel record. 3 out of 5 staff (S2-S4) records did not contain health screenings.

LPA reviewed 6 out 6 resident's Centrally Stored Medication and Destruction Records (CSMDRs). 6 out 6 CSMDRs were observed to be complete with all medication documented.

No deficiencies cited today. A technical advisory was issued. Exit interview was conducted with Director Justin Williams. A copy of this report was provided to Director.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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