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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707918
Report Date: 10/12/2022
Date Signed: 10/12/2022 10:46:14 AM

Document Has Been Signed on 10/12/2022 10:46 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 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:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Gloria KingTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Assistant Program Director (APD), Gloria King.

During visit, LPA toured the facility with APD to include the activity rooms, kitchen, bathrooms, and office. Facility temperature maintained at 71 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. Toxins and sharp objects observed secured. All staff observed wearing a face covering. All staff present are fingerprint cleared.

Facility has a designated entry point for temperature check for all clients, staff, and visitors. LPA recommended to continue symptom screening for all clients, staff, and visitors. Hand sanitizer available at entry and throughout facility. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. Trash can with lid observed. Facility staff clean and disinfect multiple times daily. LPA observed facility's Personal Protective Equipment (PPE) supplies. Facility has an isolation room to include PPE supplies and posters for isolation in use and donning and doffing. LPA advised for staff to be trained on infection control. Staff are N95 fit tested. The following posters observed to include mask required, droplet precaution, and symptoms of COVID.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Gloria King and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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