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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202784
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:17:34 PM

Document Has Been Signed on 10/03/2024 04:17 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:OAKFIELD MANOR LLCFACILITY NUMBER:
435202784
ADMINISTRATOR/
DIRECTOR:		CASIM, ELVIRAFACILITY TYPE:
735
ADDRESS:145 NORTH GADSDEN DRIVETELEPHONE:
(408) 945-9197
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 6DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Lead Staff Marites FrenandezTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Lead Staff Marites Frenandez, S1 . During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 78 degrees F, and hot water temperature was measured to range from 110-114 degrees F in resident bathrooms.

Fire extinguisher was serviced in January 10, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 1, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: OAKFIELD MANOR LLC
FACILITY NUMBER: 435202784
VISIT DATE: 10/03/2024
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LPA requested the following documents;
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC 309, Administrative Organization
6. Admission Policies and Procedures
7. A Copy of an a blank Admission Agreement
8. Articles of Incorporation or organization, Constitution and Bylaws
9. LIC610D, Emergency Disaster Plan
10 Plan of Operation
11. Transportation Arrangements/Procedures
12. Qualifications of Administrator (Certificate)
13. Please review your facility program for updates (incorporating new laws and/or regulations)
14. Please submit copy of surety bond

No deficiencies cited during today's visit. This report was reviewed with Lead Staff Marites Frenandez and a copy of the signed report was provided. (This Report was reviewed with ADM via phone call.)

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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