Community Care Licensing

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:57 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type A

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as no current liability insurance is presently in place. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	Licensee will obtain liability insurance coverage sufficient to satisfy the above requirement by the plan of corrections due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:57 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type A

Section Cited

CCR

87411(a)

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and records reviewed], the licensee did not comply with the section cited above in as only two staff members are currently providing care and supervision which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	Licensee to hire at least one additional staff member and will ensure adequate reliever coverage if needed. Documentation to be provided to LPA before the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:57 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type A

Section Cited

HSC

1569.695(a)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as there is no current emergency and disaster plan in place at the facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	Licensee will generate a valid Emergency and Disaster plan using form LIC610E before the plan of corrections due date.

Type A

Section Cited

CCR

87705(c)(3)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above as the only staff member cleared to work at the facility has no documented dementia training. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	Licensee to train and document training before the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:57 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

HSC

1569.618(c)(4)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times. 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 as lingering smells, stains and dust are observed throughout the physical plant. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to conduct extensive cleaning of the physical plant to be documented and demonstrated before the plan of corrections due date.

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as there are no reviewable staff records for the staff member currently stated to provide care and supervision to residents in addition to the licensee. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee will compile staff records including all required documentation before the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

CCR

87412(c)

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above in as there is no documented evidence of training received for staff members besides the licensee/administrator. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Required training will be arranged to be provided by licensee and documented accordingly prior to the plan of corrections due date.

Type B

Section Cited

CCR

87411(c)(6)

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onrecords reviewed, the licensee did not comply with the section cited above. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Required training will be arranged to be provided by licensee and documented accordingly prior to the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

HSC

1569.626(a)(1)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Required training will be arranged to be provided by licensee and documented accordingly prior to the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

CCR

87555(b)(23)

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. 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 as cooked rice was observed to be sitting unrefrigerated on the kitchen counter. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to ensure the absence of any potential sources of food-borne illnesses before the plan of corrections due date.

Type B

Section Cited

CCR

87465(a)(6)

(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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as no valid records of medication administration are maintainted at the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to generate and update a valid Medication Administration Records to record doses administered before the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

CCR

87506(b)(15)

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as multiple resident records are absent or incomploete. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to obtain signed admission agreeement and to complete adequate and updated appraisal for all five residents in care at the facility prior to the plan of corrections due date.

Type B

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as no pre-admission appraisal were presented for review during the facility visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Pre-admission appraisal to be conducted for all future admissions.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

CCR

87508(a)

(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as there is no updated register of all residents in place. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee will generate an updated resident register before the plan of corrections due date.

Type B

Section Cited

HSC

1569.695(a)(1)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and records reviewed, the licensee did not comply with the section cited as no current Emergency and Disaster plan is in place. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to create a valid Emergency and Disaster Plan prior to the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

HSC

1569.695(a)(5)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (5) At least two appropriate shelter locations that can house facility residents during an evacuation. One of the locations shall be outside of the immediate area. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and records reviewed, the licensee did not comply with the section cited above as no current evacuation locations have been identified. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee will ensure appropriate evacuation locations are included in the Emergency and Disaster Plan.

Type B

Section Cited

HSC

1569.695(c)

(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
1 2 3 4	Based on records reviewed and interview conducted, the licensee did not comply with the section cited above as no existing documentation of fire drills is presented during the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to schedule quarterly drills as required by regulations.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type B

Section Cited

CCR

87469(a)

(a) Upon admission, a facility shall provide each resident, and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care. This information shall include, but not be limited to, the Department's approved brochure entitled “Your Right To Make Decisions About Medical Treatment,” PUB 325, (3/12) and a copy of Sections 87469(b), (c) and (d) of the regulations. 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 as the poster is not the appropriate size. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Personal rights documentation to be provided to prospective and newly admitted residents.

Type B

Section Cited

CCR

87633(b)

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as no hospice plan of care was observed to be present during the facility visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to obtain and maintain hospice plan of care on file for the relevant residents before the plan of corrections due date.

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024

Document Has Been Signed on 07/02/2024 05:58 PM - It Cannot Be Edited

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Type A

Section Cited

CCR

87355(d)

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record reviews, the licensee did not comply with the section cited above as one staff member observed during the visit was found to not have a current background clearance on file and was later removed from the premises. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	Licensee to obtain adequate fingerprinting and background clearance for all staff members prior to adding the individuals in question to the schedule, including for shadowing and training purposes. Civil penalty assessed.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sheila Santos TELEPHONE: (714) 334-2062 LICENSING EVALUATOR NAME: Kevin Saborit-Guasch TELEPHONE: (714) 497-8754 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024