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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200286
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:27:06 PM

Document Has Been Signed on 12/22/2023 03:27 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GREEN OAK DEVELOPMENTAL CENTER IIFACILITY NUMBER:
019200286
ADMINISTRATOR:MARIA LEANOFACILITY TYPE:
775
ADDRESS:2827 WHIPPLE ROADTELEPHONE:
(510) 475-6069
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 60CENSUS: 18DATE:
12/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria LeanoTIME COMPLETED:
03:45 PM
NARRATIVE
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LPA Luisa Fontanilla conducted a case management visit related to complaint# 15-AS-20230614112727 and met with Maria Leano.

During the course of investigation, it was observed that Staff 2(S2) and Staff 4 (S4) who are both fingerprint cleared were not associated to the facility.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Leano and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2023
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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Document Has Been Signed on 12/22/2023 03:27 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/22/2023 at 02:48 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: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
82065(i)(2)

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82065(i)(2) Personnel Requirements
(i) Prior to employment or initial presence in the day program, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Section 82019(f) or
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LPA has verified from Guardian that both S2 and S4 are associated to the facility during the visit.
Deficiency is cleared.
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This requirement is not met as evidenced by:
Based on records review conducted, S2 and S4 who are fingerprint cleared were not associated to the facility which poses a potential risk toheath and safety of clients.
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023


LIC809 (FAS) - (06/04)
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