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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200481
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:56:35 PM

Document Has Been Signed on 11/09/2022 02:56 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:SVS OAKLAND ADULT DAY PROGRAMFACILITY NUMBER:
019200481
ADMINISTRATOR:RENE POCHEFACILITY TYPE:
775
ADDRESS:1830 EMBARCADERO SUITE 102TELEPHONE:
(510) 698-3990
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 60CENSUS: 38DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Rene Poche, AdministratorTIME COMPLETED:
03:10 PM
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On 11/09/22 at 2:15 pm, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Rene Poche and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to: front entrance, screening station, bathrooms and activity areas. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, participants and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPE maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for participants and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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