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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703329
Report Date: 04/23/2025
Date Signed: 04/23/2025 11:36:08 AM

Document Has Been Signed on 04/23/2025 11:36 AM - 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/
DIRECTOR:		HEATHER MOOREFACILITY TYPE:
775
ADDRESS:111 CHURCH STREET, RM. #7TELEPHONE:
(408) 354-4782
CITY:LOS GATOSSTATE: CAZIP CODE:
95030
CAPACITY: 30CENSUS: 11DATE:
04/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Linda HitchcokckTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Program Director (PD) Linda Hitchcock. During visit, LPA toured the facility inside and out.

LPA observed the kitchen area to have locked cabinets for sharp objects and cleaning supplies.

LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathrooms measured at 107 F and 109 F.

LPA Marrufo reviewed the facility records and observed the last fire detector system inspection was conducted on 11/27/2024. Three out of three fire extinguishers had service tags dated May 2024.

LPA reviewed six resident records. Resident R1's record was missing an Admission Agreement and Physician's Report. LPA reviewed the staff records for staff S1-S4. S1 and S2 were missing first aid certifications. S3 and S4 had current first aid certifications. During visit, PD stated that either S3 or S4 are always on duty. LPA reviewed the staff schedule during visit. S2 was missing a health screening form.

There was no disaster drill log kept at the facility.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. This report was reviewed with PD Linda Hitchcock and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Sarah Yip
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/23/2025 11:36 AM - It Cannot Be Edited


Created By: David Marrufo On 04/23/2025 at 11:01 AM
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: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82023(d)(2)
82023 Disaster And Mass Casualty Plan (d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented and the documentation maintained in the day program for at least one year.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records and interview with staff, the licensee did not comply with the section cited above by not maintiaining documentation of disaster drills conducted at the facility at least once per year, which poses a potential safety risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee shall conduct a disaster drill and submit documentation of the disaster drill to the department by POC Due Date.
Type B
Section Cited
CCR
82070(b)(6)
82070 Client Records (b) Each record must contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 82068.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of resident records, the licensee did not comply with the section cited above in 1 out of 6 reviewed resident records that was missing an admission agreement, which poses a potential personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee agrees to submit a copy of resident R1's Admission Agreement to the department by POC Due Date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sarah Yip
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/23/2025 11:36 AM - It Cannot Be Edited


Created By: David Marrufo On 04/23/2025 at 11:11 AM
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: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82070(b)(8)
82070 Client Records (b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 82069(b).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 1 out of 6 reviewed resident records which did not have a Medical Assessment, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee agrees to submit a copy of resident R1's Medical Assessment to the Department by POC Due Date.
Type B
Section Cited
CCR
82066(a)(10)
82066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 1 out of 4 reviewed records which was missing a health screening form, which poses/posed a potential health risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee agrees to submit a health screening form for staff S2 to the department by POC Due Date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sarah Yip
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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