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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294231
Report Date: 03/27/2024
Date Signed: 03/27/2024 12:03:50 PM


Document Has Been Signed on 03/27/2024 12:03 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
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, CA



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:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Mary Ann SisonTIME COMPLETED:
12:30 PM
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On 3/27/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with care staff Mary Ann Sison. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed some residents having breakfast at the dining room. Hot water was also tested in the bathrooms and the temperature was 109 deg F. Room temperature is at 69 deg F. The residents have adequate number of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Chemicals and sharps are observed to be locked. Emergency drills are done every quarter.

LPA reviewed five resident records and four staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs.

Medication review was done, and centrally stored medication is updated, medication cabinet is locked and inaccessible to residents.

LPA received the following documents: LIC308, LIC400, LIC500, LIC610.

LPA requested the following documents to be submitted: Control of Property, LIC309, Certificate ofLiability Insurance

This report was reviewed a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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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