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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703329
Report Date: 05/03/2022
Date Signed: 05/03/2022 04:20:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/03/2022 04:20 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LIVE OAK ADULT DAY SERVICESFACILITY NUMBER:
430703329
ADMINISTRATOR:LISA LENOCIFACILITY TYPE:
775
ADDRESS:111 CHURCH STREET, RM. #7TELEPHONE:
(408) 354-4782
CITY:LOS GATOSSTATE: CAZIP CODE:
95030
CAPACITY: 30CENSUS: 0DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ann PetersonTIME COMPLETED:
11:25 AM
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On 5/3/2022, around 10:20AM, Licensing Program Analyst (LPA) Steve Chang arrived at facility, but no one at facility. LPA waited outside of the facility around 25 minutes, then Executive Director (ED) Ann Peterson arrived at facility, and opened the door for LPA.

LPA toured the facility with ED. COVID posters were observed at the main entrance. A screening station with hand sanitizers, masks, disinfecting wipes, thermometer, and visitor log book was observed at the main entrance. Two restrooms, two classrooms and one storage room were observed. The two classrooms were observed like storage rooms. ED stated this facility has not being operating for more than two years. ED stated the facility plans to reopen, but there is no exact day scheduled to reopen.

ED stated ED is fully vaccinated and done with booster. ED stated there is no other staff for the facility.

LPA observed the facility is at non-operational status. LPA suggested to ED to close the facility if the facility is non operational.

Exit interviewed was conducted with ED. The report was provided to ED for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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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