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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202315
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:53:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/21/2022 04:53 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
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: 19DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Jamie Rivera-VallesteroTIME COMPLETED:
12:01 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Cristy Carasi Assistant Program Director (APD) and Jamie Rivera-Vallestero Program Director (PD). Upon arrival, APD took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility with APD. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. LPA toured the facility with APD. Conference rooms, activity room, class rooms, kitchen, restrooms and offices were inspected. Clients were observed in the program activity. All the staff were observed wore the masks.

Some trash cans were observed without covers. PD stated PD will put all the trash cans with covers in facility within 5 days. Posters of washing hands were observed in restrooms and kitchen. No posters of washing hands for 20 seconds were observed by the sinks in the restrooms and kitchen. PD stated PD will put the posters of washing hands for 20 seconds in the restrooms and kitchen in 5 days. PPE supplies were observed sufficient. Cleaning products were observed locked. Room temperature was at 70 degree F.

Fire extinguisher was serviced on 08/21/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by staff, and they were working fine.


PD stated all the staff are fully vaccinated and done with booster shots. PD stated the facility already submitted the Infection Control Plan to CCL office.

No citation were noted today. Exit interview was conducted with PD. A copy of this report was provided to PD.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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