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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707918
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:31:21 PM

Document Has Been Signed on 10/15/2021 03:31 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LIVE OAK ADULT DAY SERVICES- WHEELER MANORFACILITY NUMBER:
430707918
ADMINISTRATOR:ANN PETERSONFACILITY TYPE:
775
ADDRESS:651 WEST SIXTH STREET, STE. #2TELEPHONE:
(408) 354-4782
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 25CENSUS: 7DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gloria Martinez KingTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual inspection and met with Assistant Program Director (APD) Gloria Martinez-King. Facility is open Monday - Friday from 9:00am - 3:00pm.

LPA observed 7 clients socially distanced in the activity room. LPA toured the facility inside and out to include the central entry point, activity room, office, isolation room, kitchen, bathroom, and exterior. All fire exit routes were free and clear of obstructions. Toxins and cleaning supplies are secured.

Facility observed to have designated entry point for COVID-19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available to clients, visitors, and staff. LPA observed the following posters to include, required mask, feeling ill, droplet precautions, and social distancing.

LPAs reviewed the facility policies and procedures to include screening, isolation, disinfecting, staff sick leave policy, and PPE donning and doffing training.

The Department will provide additional COVID-19 resource links and PPE supplies to include gowns and N95s.

No citations were issued per the California Code of Regulations, Title 22.

LPAs reviewed report with Assistant Program Director Gloria Martinez-King and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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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