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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201427
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:20:51 PM

Document Has Been Signed on 11/30/2023 12:20 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:
435201427
ADMINISTRATOR:ANN PETERSONFACILITY TYPE:
775
ADDRESS:20920 MCCLELLAN ROADTELEPHONE:
(408) 973-0905
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 30CENSUS: 13DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Program Director, Julie HemphillTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Program Director (PD) Julie Hemphill. LPA observed 4 staff at the facility and 13 clients in the activity room.

During visit, LPA toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 115.1F - 116.6F. The water temperature in the kitchen sink was 116.6F. LPA Rai observed 3 fire extinguishers in the facility and were last services on 10/9/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The facility's last disaster drill was conducted on 07/06/2023.

PD stated the facility does not have transportation vehicles and the clients use third party vendors for transportation.

LPA Rai reviewed 2 staff files and 3 client files. During record review of R1's file, LPA Rai did not observe a written Needs and Service Plan in client's file. PD stated R1's file did not have a written Needs and Service Plan and the facilty create a Needs and Services Plan 6 months after admission date. LPA Rai reviewed California Code of Regulation 82068.2 which stated the facility needs to complete a written Needs and Services Plan no later than 30 days after admission.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Program Director, Julie Hemphill and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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 11/30/2023 12:20 PM - It Cannot Be Edited


Created By: Simranjit Rai On 11/30/2023 at 11:10 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
FACILITY NUMBER: 435201427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(e)
82068.2 Needs and Services Plan
(e) The written Needs and Services Plan specified in Section 82068.2(f), shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record revew of R1's file at the facility, the licensee did not comply with the section cited above in 1 out of 3 client's files did not maintain a written Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Program Director stated a written Needs and Services Plan will be completed and emailed to LPA Simi Rai. Program Director stated will submit written plan on understanding regulations and ensure Needs and Services Plan is created and written within 30 days of a client's admission to the facility by POC date. Program Director agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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