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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605898
Report Date: 02/13/2023
Date Signed: 02/13/2023 04:22:22 PM

Document Has Been Signed on 02/13/2023 04:22 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OLYMPIC BOARD & CAREFACILITY NUMBER:
197605898
ADMINISTRATOR:JURATE EZERSKIENEFACILITY TYPE:
740
ADDRESS:4532 ABBEY PL.TELEPHONE:
(323) 936-1018
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 6CENSUS: 4DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:House Manager Justina MillanTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with House Manager Justina Millan and explained the purpose of today's visit.

As a part of the inspection, LPA used the inspection tool, reviewed (4) resident records, (3) staff files, and (4) resident medications. This is an RCFE with a capacity of six (6). The facility is licensed to serve six (6) non-ambulatory residents, ages 60 years and over Currently the facility has (4) residents which are non-ambulatory. The facility is a residential house consisting of (4) resident bedrooms, (2) resident bathrooms, living room, dining room, kitchen, (1) room for live-in staff, covered patio with table and chairs. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #2 and #3 are equipped with two beds, a dresser, lamp, chair, overhead lightning and closet space. Bedrooms #1 and #5 are single resident rooms with the required furniture as well. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Facility has central air and heating. Supply of hygiene supplies stored for each resident observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations. Required supply of perishables and non-perishables were observed. LPA observed facility to be in good repair throughout.

Infection control domain completed and there were no deficiencies. An exit interview was conducted. Copy of this report provided
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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