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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294231
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:09:31 PM

Document Has Been Signed on 05/09/2023 02:09 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:OAK GROVE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435294231
ADMINISTRATOR:AGUILAR, DEBBIE R.FACILITY TYPE:
740
ADDRESS:5459 CENTURY PARK WAYTELEPHONE:
(408) 229-9479
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 6DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary Ann SisonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with facility staff Mary Ann Sison.

During visit, LPA Marrufo toured the kitchen area. Knives, sharp objects, and cleaning supplies were stored in a locked cabinet. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least 7 days in the kitchen refrigerator as well as in the garage refrigerators and pantry. LPA Marrufo observed the medications to be locked in a dinning room cabinet. The first aid kit was observed to be complete.

LPA Marrufo toured 1 out of 1 resident hallway bathrooms and 1 resident bedroom bathroom. Both bathrooms had available soap, paper towels, grab bars, and anti-slip mats. The bathroom water temperature measured at 114 F.

LPA Marrufo toured 5 out of 5 resident bedrooms. Each bedroom had functioning lights, available bedding, and functioning dresser drawers and storage space. LPA Marrufo tested the smoke detectors in each room as well as two additional smoke detectors in the hallways. Each smoke detector functioned properly when tested. The outdoor area was toured and the outdoor exits were clear of obstructions.

LPA Marrufo reviewed 6 out of 6 resident medications and the Centrally Stored Medication Log was found to be complete. LPA Marrufo reviewed resident and staff records.

This report was reviewed with facility staff Mary Ann Sison and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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