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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200743
Report Date: 09/13/2023
Date Signed: 09/13/2023 02:03:13 PM

Document Has Been Signed on 09/13/2023 02:03 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 SERVICESFACILITY NUMBER:
435200743
ADMINISTRATOR:ANN PETERSONFACILITY TYPE:
775
ADDRESS:1147 MINNESOTA AVE.TELEPHONE:
(408) 971-9363
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 30CENSUS: 15DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Ann PetersonTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Ann Peterson.

LPA toured the facility inside and out with ADM, which includes the lobby, the staff offices, the men's & women's restroom, the facility kitchen, outdoor deck, and the program area. Exits and pathways are free and clear of obstructions. Clients were having lunch, then had a round chair activity while LPA was touring the facility.

LPA measured the hot water temperature in the facility and it was measured at 115 F. Fire extinguishers were last inspected on May 12th 2023. The facility has a interconnected fire alarm and smoke detector system which is connected to an alarm monitoring provider which is 27/4 and will alert the local fire department. Disaster drills are conducted bi-annually. LPA asked ADM when the last fire drill was conducted. ADM stated that its been at least 8 months since their last drill. ADM stated she would conduct a drill by next week.

LPA observed Toxins and cleaning supplies are locked in a closet in the kitchen. LPA observed sharp objects and knives are locked in a closet in the kitchen. LPA observed the First Aid Kit complete.

The facility ADM stated she does not currently have any clients who need medication during day program.
LPA randomly reviewed 3 client and 2 staff files.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Ann Peterson. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 09/13/2023 02:03 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/13/2023 at 01:48 PM
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
FACILITY NUMBER: 435200743

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82023(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with ADM, the ADM did not comply with the section cited above. ADM stated its been about 8 months since the facility has had a drill, this poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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ADM stated she will conduct a drill and send documentation to LPA by POC 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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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