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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202315
Report Date: 09/24/2021
Date Signed: 09/25/2021 10:27:46 AM

Document Has Been Signed on 09/25/2021 10:27 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
CCLD Regional Office,
, CA
FACILITY NAME:GREEN OAK DEVELOPMENTAL CENTER IIIFACILITY NUMBER:
435202315
ADMINISTRATOR:JAMIE RIVERA-VALLESTEROFACILITY TYPE:
775
ADDRESS:645 GIGUERE COURTTELEPHONE:
(510) 676-4569
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 100CENSUS: 16DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Jamie Rivera-VallesteroTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Christy Carasi Assistant Program Director and Jamie Rivera-Vallestero Program Director. There are 52 participants enrolled. LPA observed 16 participants on site. The other participants engage in virtual program activities. The day program operates 5 days a week from 9:00am to 1:00pm. Activities to include academics, sensory activities, social development, training on activities of daily living, COVID 19 hygiene, exercises, walking and basket ball. All participants are screened at the time of pick-up and at the end of the program.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. No participants have medication requirements. Toxins, cleaning supplies and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available to participants. LPA observed supply of Personal Protective Equipment (PPE). COVID signs posted throughout facility.

LPA reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Christy Carasi Assistant Program Director and Jamie Rivera-Vallestero Program Director and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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