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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600559
Report Date: 07/07/2022
Date Signed: 07/07/2022 03:33:30 PM

Document Has Been Signed on 07/07/2022 03:33 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:OLIVE HOUSE, THEFACILITY NUMBER:
198600559
ADMINISTRATOR:ELAM, ANNA MARIEFACILITY TYPE:
735
ADDRESS:631 NORTH OLIVE AVENUETELEPHONE:
(626) 872-0342
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 4CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Anna Elam, AdministratorTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and met Administrator, Anna Elam. The facility is licensed for 4 developmentally disabled adults ages 18 to 59 of which 2 may be non-ambulatory.

LPA toured the facility and observed the following:
* The facility has 2 client bedrooms, 1 staff room, 2 bathrooms, living room, dining room, kitchen, family room, and an attached garage. No bodies of water or pool on site.
* COVID-19 signage are posted throughout the facility.
* The facility screens and logs the temperature of visitors.
* Beds are moved at least 6 feet apart in shared bedrooms.
* Staff room is also designated as the isolation room.
* Staff were wearing face masks.
* Knives and disinfectants are locked and inaccessible to clients.
* Smoke detectors and carbon monoxide detectors were tested and operable.
* Food supplies of 2 day perishable and a week of non-perishable were observed.
* PPE supplies of at least 30 days are in storage.
* Emergency numbers and clients' information are up-to-date.
* LPA reviewed all 4 clients' medication and compared to the MAR log. They are all given as prescribed.

LPA also conducted the Technical Assistance visit due to current covid-19 cases at the facility. LPA reminded Administrator to continue disinfecting high touch surfaces, monitor clients more closely, as well as provided information on the N95 Respirator Fit Testing. Per the Administrator, they are continuing to follow their mitigation plan to prevent the spread of the Coronavirus.
There are no citations issued today. An exit interview was held and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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