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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201427
Report Date: 11/21/2022
Date Signed: 11/21/2022 11:37:10 AM

Document Has Been Signed on 11/21/2022 11:37 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 SERVICESFACILITY NUMBER:
435201427
ADMINISTRATOR:ANN PETERSONFACILITY TYPE:
775
ADDRESS:20920 MCCLELLAN ROADTELEPHONE:
(408) 973-0905
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 30CENSUS: 13DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Lisa LenociTIME COMPLETED:
11:40 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 Program Director, Lisa Lenoci.

During visit, LPA toured the day program to include the office, kitchen, bathrooms, activity rooms, and backyard. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. All staff observed wearing a face covering.

Facility has a designated entry point for symptom screening, temperature check, and sign in for all staff, clients, and visitors/volunteers. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with hygiene products, paper supplies, and hand-washing signs. LPA observed facility's Personal Protective Equipment (PPE) supplies and lidded trash bin. Facility has a PPE supply bin to include a donning and doffing poster. LPA reviewed the facility's procedures to isolation. Facility staff clean and disinfect multiple times day. Staff are trained on infection control. The following posters observed to include symptoms of COVID, mask required, and cough etiquette.

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

This report was reviewed with Lisa Lenoci and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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