<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200286
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:00:08 PM

Document Has Been Signed on 01/15/2025 02:00 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GREEN OAK DEVELOPMENTAL CENTER IIFACILITY NUMBER:
019200286
ADMINISTRATOR/
DIRECTOR:		MARIA LEANOFACILITY TYPE:
775
ADDRESS:2827 WHIPPLE ROADTELEPHONE:
(510) 475-6069
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 60CENSUS: 15DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Maria Leano, Program Director TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/15/2025 at 12:30 PM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Program Director, Maria Leano, and explained the purpose of the visit. Day program operates from Monday to Friday 8:30 AM- 2:30 PM.

During the visit, LPAs inspected the Adult Day Program (ADP) including but not limited to bathrooms, activity rooms such as kitchen, Paradise Room, Woodside and Ocean Room, and 3 bathrooms. Hot water temperature measured at 112.3 degrees Fahrenheit in the bathroom. There were multiple fire extinguishers observed which appeared full and last serviced on 07/29/2024.

LPA reviewed 5 staff and 6 client files. All staff are fingerprint cleared and associated to the ADP and have First Aid Certification. P & I money and log were reviewed. ADP has surety bond sufficient to cover amount of money being handled at one time.

The following forms to be updated and submitted to CCLD by 01/22/2025

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610 Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Program Director. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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 3
Document Has Been Signed on 01/15/2025 02:00 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/15/2025 at 01:51 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREEN OAK DEVELOPMENTAL CENTER II
FACILITY NUMBER: 019200286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(c)
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having one of the emergency exit doors t is rusted and is difficult to open which poses a potential health and safety risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
1
2
3
4
The Program Director agrees to fix the exit door and make it accessible, and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3