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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707918
Report Date: 10/25/2024
Date Signed: 10/25/2024 12:16:56 PM

Document Has Been Signed on 10/25/2024 12:16 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 SERVICES- WHEELER MANORFACILITY NUMBER:
430707918
ADMINISTRATOR/
DIRECTOR:		HEATHER MOOREFACILITY TYPE:
775
ADDRESS:651 WEST SIXTH STREET, STE. #2TELEPHONE:
(408) 354-4782
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 25CENSUS: 12DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Alexa NavarreteTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Program Director, Alexa Navarrete.

During visit, LPA toured the facility with PD to include the activity rooms, kitchen, bathrooms, and office. Clients observed participating in program. Two staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 74 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. Carbon monoxide detector observed in the kitchen. Fire extinguisher last serviced on 01/15/2024.
Cleaning supplies and sharp objects observed locked and stored in separate areas. The day program does not store and handle any client medications. Bathroom hot water temperature maintained at 120 degrees F. Bathroom supplied with toilet paper, paper towels, soap and grab bars. LPA observed a first aid kit, flash lights and batteries.

4 resident files were reviewed and observed them to be complete. 3 staff files were reviewed. At least one staff present has a first aid certification. 3 staff obtains a food handler certification. 2 out of 3 direct care staff files did not contain documented 8 hours of annual training. The review of records shows that S1 has 3.50 hours of annual training and S2 has 50 minutes of annual training. Emergency drills are conducted quarterly and the last drill was completed in September 2024. Facility has an emergency disaster plan and infection control plan.

A deficiency was cited per California Code of Regulations, Title 22. This report was reviewed with Program Director, Alexa Navarrete and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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 10/25/2024 12:16 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/25/2024 at 11:45 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- WHEELER MANOR
FACILITY NUMBER: 430707918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above wherein 2 staff members did not have a documented of 8 hours of training as S1 had 3.50 hours and S2 had 50 minutes of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee will ensure all direct care staff receive at least 8 hours of training a year. Licensee will submit the facility's plan of operations regarding the staff annual training plan. Licensee will submit the POC to LPA Dolores via email by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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