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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803486
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:01:38 AM

Document Has Been Signed on 07/23/2024 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OLIVE HOUSEFACILITY NUMBER:
216803486
ADMINISTRATOR/
DIRECTOR:
SCUTT, JACQUES P.FACILITY TYPE:
735
ADDRESS:1301 OLIVE AVENUETELEPHONE:
(415) 847-2087
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 4CENSUS: 4DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator, Jacques ScuttTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:10AM to conduct an Annual Required inspection and was greeted by Administrator, Jacques "Phil" Scutt. LPA and Administrator discussed the purpose of the visit.

LPA and Administrator initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 115 and 118 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Closets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Emergency food and water is stored in the garage and is frequently rotated. Fire extinguishers were last serviced 02/07/2024. Smoke and carbon monoxide detectors were tested and operational during inspection. Most recent disaster drill was conducted 06/01/2024.


Four client files were reviewed. Client files contained all required documents. LPA reviewed staff files. Staff files contained all required documents. Medications and medication records were reviewed. Medications were documented as per regulation. Client cash resources were reviewed. Cash resources were documented as per regulation. Administrator certificate for Jacques Scutt (7003045735) is up to date and expires 10/24/2025.

No deficiencies cited during inspection.


Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OLIVE HOUSE
FACILITY NUMBER: 216803486
VISIT DATE: 07/23/2024
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Continued from LIC809

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 07/23/2024:

LIC 500 Personnel Report

LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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