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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202928
Report Date: 12/11/2024
Date Signed: 12/11/2024 10:47:40 AM

Document Has Been Signed on 12/11/2024 10:47 AM - 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 INC SPRING AVENUE HOMEFACILITY NUMBER:
435202928
ADMINISTRATOR/
DIRECTOR:		FERRER, ORLANDOFACILITY TYPE:
735
ADDRESS:170 SPRING AVENUETELEPHONE:
(408) 727-3493
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 5CENSUS: 0DATE:
12/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Orlando Ferrer, Felicia Lehner, Dana CooperTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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Licensing Program Analysts (LPAs) Christine Dolores and Kenneth Madrigal arrived announced to conduct the pre-licensing visit. LPAs met with Orlando Ferrer (Administrator), Felicia Lehner (Program Manager), and Dana Hooper (Executive Director).

There are no residents on-site. The facility is approved for 5 ambulatory in which 3 may be non-ambulatory. Bedroom #1 and bedroom #2 are approved for non-ambulatory.

Bedroom #1 and Bedroom #2 contains an emergency exit door which leads into the backyard. The emergency exit contains a ramp and hand rails. Bedroom #1 and Bedroom #2 is equipped with a closet space, adequate lighting, and a private bathroom. Bathroom hot water temperature maintained at 107.4 degrees F. Shower is equipped with non-slip floors and a grab bar above the toilet. The showers in bedroom #1 and bedroom #2 does not contain grab bars. Applicant states a plan to install grab bars for the showers of bedroom #1 and bedroom #2. The bedrooms are supplied with beds, linens, night stands, closet space, dressers, and adequate lighting.

Bathroom hot water temperature in the hallway is maintained at 106.3 degrees F. The bathroom shower contains a non-slip mat. LPAs observed the mirror above the sink is not sturdy as LPA was able to move the mirror on the wall.

LPAs observed locks on the drawers and cabinets that will store chemicals/disinfectants and sharp objects in the kitchen. Refrigerator temperature maintained at 45 degrees F. Freezer temperature maintained at 0 degrees F. Facility has at least a 7 day supply of non-perishable foods. Fire extinguisher serviced on 10/03/2024. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 INC SPRING AVENUE HOME
FACILITY NUMBER: 435202928
VISIT DATE: 12/11/2024
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Garage will be intended to be used for an office space. LPA advised applicant to ensure the paint cans and tubs of chemicals/toxins will be kept inaccessible to residents in care. Applicant stated understanding. Laundry appliances observed in the garage. There is a cabinet to store laundry supplies, in which the applicant plans to purchase a lock for.

All emergency exit routes are clear and free and obstruction. Facility has a thermostat and heater. Temperature maintained at 68 degrees F. Facility has an operable carbon monoxide detector and smoke detectors.

The backyard has a shaded area but there was no furniture such as tables and chairs observed. The applicant states they have ordered an outdoor seating set which includes chairs and a table, and are still waiting for their shipment of the outdoor furniture. The backyard is equipped with a permitted ADU which will be used to house live-in staff. The ADU contains a lock. LPAs entered and toured the ADU which contains a small kitchen, bedroom, bathroom, laundry room, and living room area

Facility has an emergency supply to include non-perishable foods, flashlights, and batteries. Each resident will have a grab and go backpack. Posters observed to include if you see something say something, evacuation map, and personal rights. Facility has a place to lock records and medication.

COMP III was reviewed with Orlando Ferrer, Felicia Lehne, and Dana Hooper.

Pre-Licensing is incomplete with deficiencies to be resolved by 12/18/2024. A follow-up pre-licensure LIC809 will be generated upon resolution of deficiencies.

This report was reviewed with Orlando Ferrer, Felicia Lehne, and Dana Cooper and a copy of the report was provided.
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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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