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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202315
Report Date: 11/05/2021
Date Signed: 05/02/2024 09:38:39 AM

Document Has Been Signed on 05/02/2024 09:38 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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: 14DATE:
11/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jamie Rivera-VallesteroTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Steve Chang, licensing Program Manager (LPM) Romeo Manzano, Program Clinical Consultant (PCC) Helen Shi, and San Andreas Regional Center (SARC) Registered Nurse (RN) Lisa Runds conducted Technical Assistant - PCC through tele-inspection (Zoom) , and met with Program Director (PD) Jamie Rivera-Vallestero.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance to include screening questionnaires, hand sanitizer, face masks, thermometer, gloves, and a visitor log book. PD stated currently the facility does not allow visitors. PD stated the screening questionnaires are for staff and clients. PD read the questionnaires to LPA and PCC nurse.

LPA toured the two offices with PD, and checked the facility PPE supplies. PPE supplies were observed sufficient. Front desk, hallway, 4 class rooms and kitchen were inspected. Hallway floor has marks for social distance. Desks in Classrooms were observed for single and 6 feet apart. Trash cans except the one in kitchen were observed with covers. It is recommended to replace he trash can in kitchen with one with cover. PD agrees to replace the trash can in kitchen. recreation room, two restrooms, and isolation room were observed. It is recommended to put the signage on the isolation room.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: GREEN OAK DEVELOPMENTAL CENTER III
FACILITY NUMBER: 435202315
VISIT DATE: 11/05/2021
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Clients were observed outside the building for activity. Clients were observed kept social distance.

Mitigation plan were discussed with PD. PD stated all the staff are fully vaccinated. PD stated all the staff had N95 fitting test. PD stated kitchen was closed for use.

Based on today's inspection, the facility is being recommended the following:

1. Recommend trash cans/bins with cover and foot pedal.

2. Recommend to put signage on the designated isolation room.

3. Disinfect more often for high touch area.

4. Ask client the screening questions before clients ride on the vehicle.

5. Take client's body temperature before clients ride on the vehicle.

6. Provide more PPE to facility drivers.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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