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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200288
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:36:28 PM

Document Has Been Signed on 12/28/2023 03:36 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 CENTERFACILITY NUMBER:
019200288
ADMINISTRATOR:GINA RIVERAFACILITY TYPE:
775
ADDRESS:2949 WHIPPLE ROADTELEPHONE:
(510) 441-8300
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 80CENSUS: 29DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gina RiveraTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day at around 11:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Program Administrator Gina Rivera. LPA explained to Administrator the purpose of the visit.

During the visit, LPA inspected the Adult Day Program (ADP) including but not limited to bathrooms, activity rooms such as Flower Room, Circle Room, Sensory Room and the main area. Hot water measured at 118.6 degrees Fahrenheit in one client bathroom. There were multiple fire extinguishers observed which appeared full and last serviced on 7/18/2023. Room temperature was observed at 69 Fahrenheit.

LPA reviewed 5 staff and 5 client files. All staff are fingerprint cleared and associated to the ADP. LPA interviewed 3 staff and attempted to interview 3 clients. P & I money and log were reviewed. ADP has surety bond sufficient to cover amount of money being handled at one time.

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

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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 12/28/2023 03:36 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/28/2023 at 03:27 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
FACILITY NUMBER: 019200288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having S5 health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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By POC date, Administrator will send a copy of S5 health screening to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
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