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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200743
Report Date: 09/23/2021
Date Signed: 09/23/2021 02:53:42 PM

Document Has Been Signed on 09/23/2021 02:53 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 SERVICESFACILITY NUMBER:
435200743
ADMINISTRATOR:MARQUEZ RANSOMFACILITY TYPE:
775
ADDRESS:1147 MINNESOTA AVE.TELEPHONE:
(408) 971-9363
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 30CENSUS: 10DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ann PetersonTIME COMPLETED:
10:30 AM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Executive Director, Ann Peterson.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, all exits are free of obstructions, emergency contact for residents were up to date, facility screening protocols were in effect, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Executive Director, Ann Peterson, for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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