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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200743
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:52:48 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/21/2022 04:52 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:ANN PETERSONFACILITY TYPE:
775
ADDRESS:1147 MINNESOTA AVE.TELEPHONE:
(408) 971-9363
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 30CENSUS: 28DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ann PetersonTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Executive Director (ED) Ann Peterson. Upon arrival, ED took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility with ED. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. LPA toured the facility with ED. Program room, activity room, kitchen, dining area, restrooms, staff area, offices and staff restrooms were inspected. 6 clients were observed in the program activity. All the staff were observed wore the masks.

Some trash cans were observed without covers. ED stated ED will put all the trash cans with covers in facility within 5 days. Paper towels in kitchen were observed without holder. ED stated the facility will put the paper towels with holders in 5 days. No posters of washing hands for 20 seconds were observed by the sinks in the restrooms. ED stated ED will put the posters of washing hands for 20 seconds in the restrooms in 5 days. PPE supplies were observed sufficient. Cleaning products were observed locked. Room temperature was at 69 degree F.

Fire extinguisher was serviced on 05/12/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors.

ED stated all the clients and staff are fully vaccinated. ED stated the facility already submitted the Infection Control Plan to CCL office.

No citation were noted today. Exit interview was conducted with ED. A copy of this report was provided to ED.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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