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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202315
Report Date: 09/09/2024
Date Signed: 09/09/2024 01:10:33 PM

Document Has Been Signed on 09/09/2024 01:10 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:GREEN OAK DEVELOPMENTAL CENTER IIIFACILITY NUMBER:
435202315
ADMINISTRATOR/
DIRECTOR:		JAMIE RIVERA-VALLESTEROFACILITY TYPE:
775
ADDRESS:645 GIGUERE COURTTELEPHONE:
(510) 676-4569
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 100CENSUS: 36DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Jaime River-Vallestero Administrator TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 09/09/2024 Licensing Program Analyst (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM). During the visit, ADM stated the census was 36 clients and 11 staff.

LPAs toured the facility inside out with ADM included the kitchen, restrooms and client rooms 1-4. LPAs observed clients drawing and crafts. The staff area of the facility was also inspected. The front and back of day program were inspected. There was no obstruction to block the walkways.

LPA observed the knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 71 degrees F, and hot water temperature was measured at 110 degrees F in both resident bathrooms.

Fire extinguisher was serviced in 07/24/2024. The facility was equipped with smoke and carbon monoxide detectors. ADM stated Smoke detectors were inspected by Bay Area Alarm on 09/09/2024 Annual Inspection and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last fire drill was on 06/24/2024.

LPA reviewed facility records for 3 staff and 3 clients. ADM stated no client take medications at Day Program. LPA conducted interviews with 3 staff and 3 clients.

No deficiencies cited during today's visit. This report was reviewed with Jaime Rivera-Vallestero and a copy of the signed report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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