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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202841
Report Date: 04/24/2025
Date Signed: 04/24/2025 12:56:31 PM

Document Has Been Signed on 04/24/2025 12:56 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:
04/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Staff Shane NavarroTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management incident visit. LPA met with Staff S1. LPA spoke with Administrator (ADM) Justin Wiliams via phone. ADM stated he was in training and authorized S1 to sign on his behalf. LPA observed 2 clients and 1 staff during the visit. S1 states 4 clients were at work.

On 4/16/2025 the Department received 6 Incident Reports regarding bed bugs at the facility. The Incident Reports state bedbugs were first observed on 3/4/2025 in R1's bedroom and the facility called an exterminator. The Incident Report states the facility is monitoring for bedbugs and the exterminator will conduct follow up treatments.

LPA toured the facility with S1 to include 6 clients bedrooms, dining area, and living room. LPA inspect mattresses, bedding and client furniture. LPA observed 6 clients mattresses with mattress encasements (zip up covers).

LPA interviewed ADM, 2 staff and 2 clients. ADM states bedbugs were observed about a month ago, and the facility was treated by an exterminator. ADM states the facility has had 3 follow up treatments by the exterminator. ADM states the most recent exterminator treatment was on 4/16/2025. ADM states bedbugs were found in R1's bedroom and in the facility living room couch.


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NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/24/2025
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LPA interviewed 2 staff. 2 out of 2 staff state the facility had bedbugs. S2 states bedbugs were found in R1's bedroom and the facility living room couch.

LPA interviewed 2 clients. 2 out of 2 clients state the facility has bedbugs.

The facility provided LPA with the Terminix exterminator treatment report dated 2/27/2025.

Two citations were issued during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Staff Shane Navarro and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 12:56 PM - It Cannot Be Edited


Created By: Marcella Tarin On 04/24/2025 at 11:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIFE SERVICES ALTERNATIVES HATIKVAH HOUSE
FACILITY NUMBER: 435202841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2025
Section Cited
CCR
80061(a)(b)

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80061 Reporting Requirements: (a)(b) Each licensee... shall furnish to the licensing agency reports...within the agency's next working day... a written report...submitted... within seven days.
This requirement was not met as evidenced by:
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Licensee states the facility will submit a Plan of Action and how they will monitor for bedbugs by conducting body checks on clients, and check bedding daily to ensure the health and safety of clients in care. Licensee will also submit a statement of understanding of the regulation cited. Licensee to submit POC by POC due date 5/1/2025.
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Based on record review and interviews, the facility did not submit an report that the facility was being treated for bedbugs on 2/27/2025. The facility submitted an incident report for bedbugs to the Department on 4/16/2025.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 12:56 PM - It Cannot Be Edited


Created By: Marcella Tarin On 04/24/2025 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIFE SERVICES ALTERNATIVES HATIKVAH HOUSE
FACILITY NUMBER: 435202841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2025
Section Cited
CCR
80087(a)(1)

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80087 Buildings and Grounds(a)(1): The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidence by:
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Licensee states the facility will submit a Plan of Action and how they will monitor for bedbugs to ensure the health and safety of clients in care due by POC due date 4/25/2025.
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Based on observation, record review and interview the licensee did not ensure resident R1's bedroom were free from bedbugs on 3/4/2025, which poses an immediate health, safety and personal rights risk to 6 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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