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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703329
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:43:28 PM

Document Has Been Signed on 03/19/2024 12:43 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
CENTRAL COAST CR/RES, 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: 11DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Lisa LenociTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Lisa Lenoci. During the visit, LPA observed 11 residents and 3 staff.

LPA toured the facility with ADM which included the Activity room 1-3, and men's and women's restrooms. There was no obstruction to block the walkways.

LPA observed the knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 108 degrees F in both resident bathrooms.

Fire extinguishers in activity room 1,2 & 3 were last serviced on March 9, 2020. (Photographs taken). The facility was equipped with smoke and carbon monoxide detectors. . LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 25, 2023. LPA reviewed facility records for 3 staff and 3 residents. ADM stated none of her clients take medication during their stay at the day program. LPA conducted an interview with 1 staff.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Lisa Lenoci and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 03/19/2024 12:43 PM - It Cannot Be Edited


Created By: Manuel Monter On 03/19/2024 at 12:22 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIVE OAK ADULT DAY SERVICES
FACILITY NUMBER: 430703329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82023(b)(2)
Disaster and Mass Casualty Plan
(b) The plan shall be subject to review by the licensing agency and shall include: (2) Contingency plans for action during fires, floods, and earthquakes including, but not limited to, the following:

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. 3 Out of 3 facility fire extinguishers inspected in the facility were last serviced on March 9, 2020. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure facility fire extinguishers are serviced annually. ADM stated she will send the plan of action by POC date, March 26, 2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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