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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005532
Report Date: 04/28/2022
Date Signed: 04/28/2022 10:46:09 AM

Document Has Been Signed on 04/28/2022 10:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:OLIVA HOMES INCFACILITY NUMBER:
306005532
ADMINISTRATOR:HILTON ANGELO PAGAYONANFACILITY TYPE:
735
ADDRESS:500 S WEST STTELEPHONE:
(714) 740-1794
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 3DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Hilton Angelo Pagayonan, Anna Liza TorculasTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection visit in this facility. LPA met with staff Ana Liza Torculas and Administrator Hilton Angelo Pagayonan and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory. Currently 3 residents reside in the facility. This facility offers a Level IV- care.

About 9:00 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed three clients in care and one staff member and Administrator on duty. LPA toured the interior and exterior portions of the facility. There were three private client rooms and one vacant room. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and hot water was measured at 106.3 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and hot water was measured at 110.4 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Kitchen was in good repair with knifes kept locked. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Facility offers a 2 car garage which is used for storage and one car. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. A ladder was removed so residents could not access it. Laundry room was in good repair with toxins locked so residents could not access them. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: OLIVA HOMES INC
FACILITY NUMBER: 306005532
VISIT DATE: 04/28/2022
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For this visit, no deficiency was noted in areas observed. No citation was issued. No advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Hilton Angelo Pagayonan and copy of this report was explained and left in the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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