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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200481
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:31:06 PM

Document Has Been Signed on 10/03/2024 01:31 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/
DIRECTOR:		RENE POCHEFACILITY TYPE:
775
ADDRESS:1830 EMBARCADERO SUITE 102TELEPHONE:
(510) 698-3990
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 60CENSUS: 47DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Program Director, Rene PocheTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 10/03/2024 at 11:40 AM, Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Program Director Rene Poche and explained the purpose of the visit. Day program operates from 7:00 a.m. to 3:30 p.m. Monday to Friday. There were 17 staff observed working at the program today.

LPA toured facility including but not limited to: activity rooms, kitchen, bathrooms and office space. Clients bring their own lunches. Emergency supplies, including water were observed. The hot water temperature in the kitchen measured 129 degrees Fahrenheit. Cleaning supplies are locked and inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition, and additional equipment for the physically handicapped was observed. Incontinent clients are kept clean and dry, and the facility is free of odors. The program has 10 vans used for client outings and transportation.

Emergency disaster drills are conducted on a quarterly. Fire extinguishers throughout facility were last inspected 07/12/2024. First aid kit was checked and observed to be complete.

LPAs reviewed 5 participant records and 5 staff records, and all were complete.

REPORT CONTINUES ON LIC 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PROGRAM
FACILITY NUMBER: 019200481
VISIT DATE: 10/03/2024
NARRATIVE
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REPORT CONTINUED FROM LIC809

THE FOLLOWING DEFICIENCY WAS OBSERVED:

LPAs observed that the hot water temperature in the kitchen sink was measured at 129 Degree F.

The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 01:31 PM - It Cannot Be Edited


Created By: Gregory Clark On 10/03/2024 at 01:11 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: SVS OAKLAND ADULT DAY PROGRAM
FACILITY NUMBER: 019200481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, hot water in the kitchen sink was measured at 129 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Program Director will adjust tempature and send a proof to CCL by POC date.
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:Gregory Clark
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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