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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605898
Report Date: 02/27/2025
Date Signed: 02/27/2025 01:59:17 PM

Document Has Been Signed on 02/27/2025 01:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OLYMPIC BOARD & CAREFACILITY NUMBER:
197605898
ADMINISTRATOR/
DIRECTOR:		JURATE EZERSKIENEFACILITY TYPE:
740
ADDRESS:4532 ABBEY PL.TELEPHONE:
(323) 936-1018
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 6CENSUS: 6DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:34 AM
MET WITH:Jurate Ezerskiene - Administrator TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jurate Ezerskiene and explained the reason for the visit.

The facility is licensed to served 6 non-ambulatory residents over the age of 60, with a hospice waiver for 6. The facility is located in a residential area and consist of a single home with 4 resident bedrooms, 2 bathrooms, a kitchen, a living room, a dining room, a staff room, and a back yard. The home has a second unit in the back which is not part of the license.

LPA conducted a tour of the facility and observed the following:
Facility is in good repair. Living and dining rooms were observed clean with sufficient furniture for residents. Activity supplies were observed in the dining room area. Medications were locked in a cabinet in the living room. Kitchen area was observed clean and in good repair and is not accessible to the residents. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. No special diets were noted by residents' physicians.
A total of 4 resident bedrooms were observed in good repair, with sufficient lighting and bedding supplies. Bedroom #1-5(BR1-5) were observed with full and half bed rails. Oxygen signs were posted as required. Two bathrooms were observed to be clean and in good repair, with skid strips and grab bars. Water temperature was tested between 114.8-115.5 degrees F. which is within the required temperature.
Carbon monoxide/Smoke detectors were tested and are in working condition. Fire extinguisher was observed in hallway. Required posters were observed in the hallway and dining room.
Outdoor area was observed with personal items clutter on top of covered seating area, on the right to the building blocking passageway and exit driveway. Exit doors were observed without auditory devices and facility services residents with dementia.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898
VISIT DATE: 02/27/2025
NARRATIVE
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Medications were reviewed for 6 residents. Medications listed on physician's orders were not observed during review for Resident #4-6(R4-R6).

Files were reviewed for 6 residents. Resident #5(R5) is not on hospice and does not have a request for full bed rails, full bed rails were observed in bed(BR1). Resident #3(R3) does not have a notification of sharing a bedroom with a resident in hospice and does not have a half bed rail request on file. Resident #2(R2) does not have a full bed rail request on file. Full bed rails were observed in bed. Resident #6(R6) does not have a half bed rail request on file. Resident #4(R4) does not have a full bed rail request on file.

LPA reviewed 2 staff files. Per resident recently 2 staff have quit and are in the process of hiring staff. Administrator certificate was observed for JURATE EZERSKIENE #601608740 exp. date: 4/29/24. Per administrator no documentation or education has been completed for renewal. Staff #2 did not have Health screening or TB test on file. First aid training has not been completed for either staff.

Emergency disaster and infection control plans were reviewed. Emergency disaster plan version (10/03) was observed which does not meet the requirements of version (12/21).

LPA interviewed 2 residents and 2 staff.

Deficiencies were noted per Title 22 Regulations.

Exit interview was conducted with Jurate Ezerskiene and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 02/27/2025 01:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/27/2025 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 residents, R5's bed was observed with full bed rails and does not have a full bed rail request and it is not on hospice services which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator will contact physician and request a bed rail request. Based on physician's request the administrator will either provide half bed rails or full bed rails. If full bed rails are provided administrator will submit an exception request to the department for postural support by POC due date 2/28/25.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 residents have dementia noted on physician's report and no auditory devices were observed on exit doors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator will install auditory devices to exit doors and will submit a picture to the department by POC due date 2/28/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 02/27/2025 01:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/27/2025 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in staff #2 does not have a TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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Administrator will ensure S2 obtains a TB test clearance and submit a copy to the department by POC due date 4/3/25.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 02/27/2025 01:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/27/2025 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff do not have a current first aid/CPR training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator will ensure self and S2 take CPR/First aid training and submit a copy to the department by POC due date 3/6/25.
Type B
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in there are currently 2 staff covering all shifts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator will ensure there is sufficient staff to cover each shift allowing rest periods and will submit a copy of LIC 500 listing all staff by POC due date 3/6/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 02/27/2025 01:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/27/2025 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in administrator has not submitted documents to renew administrator certificate and certificate #6016708740 expired on 4/29/24 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator will complete 40 hours of training and will mail out the require documents to Administrator Certification department and submit a copy of previous and mail certification to the department by POC due date 3/12/25.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in staff have not been provided 20 hours of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator will ensure staff are provided 20 hours of training including the 4 hours on postural supports, restricted health conditions, and hospice care and submit a copy to the department by POC due date 3/6/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 02/27/2025 01:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/27/2025 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 residents did not have medications listed on medication records available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator will ensure medication list is updated and the medications are available for each resident and submit a copy of medication list and medications for R4-R6 to the department by POC due date 3/6/35.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in facility has not conducted an emergency drill since 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator will conduct an emergency drill, will ensure to conduct a drill every three months, and will maintain a log for drills available for review, and submit a copy to the department by POC due date 3/6/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 02/27/2025 01:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/27/2025 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 residents have either full bed rails or half bed rails and do not have a physician's rail request on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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2
3
4
Administrator will submit a copy of bed rail physician's request for R3,R4,R6 to the department by POC due date 3/6/25.
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in passageways and outdoor area was observed clutter with personal items which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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3
4
Administrator will clear outdoor space and passageways of clutter and obstructions and submit a picture to the department by POC due date 3/6/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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