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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201427
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:11:35 PM

Document Has Been Signed on 11/15/2024 01:11 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/
DIRECTOR:
HEATHER MOOREFACILITY TYPE:
775
ADDRESS:20920 MCCLELLAN ROADTELEPHONE:
(408) 973-0905
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 30CENSUS: 16DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Assistant Program Director, Amy HallidayTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Assistant Program Director, Amy Halliday. LPA Rai observed 4 staff and 16 clients at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 1 shed in the backyard which was locked and used for storage and not habitual space.

LPA Rai toured the facilty to include 2 activity rooms, 2 restrooms, kitchen and office. LPA Rai toured the facility kitchen and office and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Third party vendor provides meals and food warmer was clean and in working condition. Sharps and medications were locked in secured areas.

The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 117.3 - 117.5 degrees F.

Fire extinguisher was observed and inspected on 10/1/2024. Facility smoke detectors and carbon monoxide detectors were inspected by the Fire Department on 3/22/2024. The last disaster drill was scheduled for September and October 2024.

LPA Rai reviewed facility records for 2 staff and 3 clients.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Assistant Program Director, Amy Halliday. and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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