075601238-6-28-2021-15-AS-DPAO-C4ETAT-20210628143405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601238
Report Date: 06/28/2021
Date Signed: 06/28/2021 02:34:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	OLYMPIC RESIDENTIAL CARE HOME		FACILITY NUMBER:	075601238
ADMINISTRATOR:	GOZUN, CONCHITA Q.		FACILITY TYPE:	740
ADDRESS:	2252 OLYMPIC DRIVE		TELEPHONE:	(925) 370-7338
CITY:	MARTINEZ	STATE: CA	ZIP CODE:	94553
CAPACITY:	6	CENSUS: 5	DATE:	06/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Catalina Atienza, House Manager		TIME COMPLETED:	02:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/28/21 at 1PM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with house manager. LPA observed administrator was not available during visit. LPA spoke with Administrator on the phone who authorized the house manager to sign the reports. LPA observed one central entry point designated for universal entry screening at the main entrance. LPA observed no visitors' log at the screening station for recording temperature logs for residents, staff and visitors. House manager agreed to document routine symptom checks daily in a visitor's log for residents, staff and visitors. LPA observed S1 and S2 were wearing face masks during visit. Facility has a completed mitigation plan in place dated 06/01/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. Pathways were observed free of obstruction and fire hazards. Per staff, the designated infection control leader is the administrator. All staff and residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OLYMPIC RESIDENTIAL CARE HOME	FACILITY NUMBER: 075601238
	VISIT DATE: 06/28/2021

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Facility room temperature was maintained at 75 degrees Fahrenheit. Smoke and Carbon monoxide detectors were operational. Centrally stored medications were locked in dining room cabinets. Toxic chemicals were locked in the garage. Sharps were observed locked underneath the kitchen sink. Fire extinguisher was observed fully charged and last inspected on 10/20/20. A written Emergency/Disaster plan dated 01/01/2020 was displayed in the kitchen area.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/07/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies were cited during this visit.
Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC809 (FAS) - (06/04)

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