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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200288
Report Date: 01/03/2025
Date Signed: 01/03/2025 01:17:52 PM

Document Has Been Signed on 01/03/2025 01:17 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 CENTERFACILITY NUMBER:
019200288
ADMINISTRATOR/
DIRECTOR:		GINA RIVERAFACILITY TYPE:
775
ADDRESS:2949 WHIPPLE ROADTELEPHONE:
(510) 441-8300
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 80CENSUS: 55DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Gina Rivera, Program Director TIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 01/03/2025 at 11:00 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Program Director, Gina Rivera, and explained the purpose of the visit. Day program operates from Monday to Friday 8am-3pm.

During the visit, LPAs 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 temperature measured at 121 degrees Fahrenheit in one client bathroom. There were multiple fire extinguishers observed which appeared full and last serviced on 06/30/2024. Room temperature was observed at 69 degrees Fahrenheit.

LPA reviewed 5 staff and 10 client files. All staff are fingerprint cleared and associated to the ADP. LPAs interviewed 2 staff and no clients was available for interview. P & I money and log were reviewed. ADP has surety bond sufficient to cover amount of money being handled at one time.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:30 AM, LPAs observed one of the exit doors was blocked with trash bins and moveable partition covering the exit door.

At 11:45 AM, LPAs observed the hot water temperature measured at 121 degrees F in 2 of the 4 bathrooms.

The Facility was 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 was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 2
Document Has Been Signed on 01/03/2025 01:17 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/03/2025 at 12:40 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: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(c)
Buildings and Grounds
(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
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Based on observation the licensee did not comply with the section cited above in having one of the exit door was blocked with trash bin and moveable partition covering the exit door which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/04/2025
Plan of Correction
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Staff removed the items blocking the passageway during the visit. Deficiency cleared.
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in having the hot water temperature measured at 121 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/04/2025
Plan of Correction
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Staff adjusted the water temperature to 118 degrees Fahrenheit during the visit. Deficiency cleared.
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: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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