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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701012
Report Date: 05/05/2021
Date Signed: 05/05/2021 02:28:54 PM

Document Has Been Signed on 05/05/2021 02:28 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:OLYMPUS RIDGEFACILITY NUMBER:
312701012
ADMINISTRATOR:KURTZ, DIANAFACILITY TYPE:
740
ADDRESS:248 SKOPAS CT.TELEPHONE:
(916) 540-7159
CITY:ROSEVILLESTATE: CAZIP CODE:
95561
CAPACITY: 6CENSUS: 6DATE:
05/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Diana KurtzTIME COMPLETED:
02:30 PM
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On May 5, 2021 at 1:30 PM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone to conduct an announced Pre-Licensing Tele-Inspection due to COVID-19 and pre-cautionary measures.

LPA was allowed entry into the facility via Facetime. LPA toured the indoor and outdoor premises with Administrator, Diana Kurtz, to ensure there are no health and safety concerns. Indoor and outdoor passageways were free of obstructions. Upon entering the facility LPA observed required COVID-19 signages. LPA observed a screening station with PPE supplies such as masks, thermometer, hand sanitizers, and sign in and out sheet.

The facility has a total of four (4) bedrooms and two (2) bathrooms. LPA observed all four (4) residents' bedroom has two exits. Exits from all bedrooms leads to the backyard. All four bedroom exits has an alarm system. LPA observed the dining room, living room, kitchen, garage, backyard and residents' bedrooms and bathrooms. LPA observed knives/shapes were locked in the kitchen cabinet located underneath the sink. LPA observed mounted fire extinguisher on the kitchen wall. Fire extinguisher was purchased on 2/22/2021. LPA observed food supplies for non-perishable for a minimum of one (1) week and two (2) days of perishable. LPA observed cleaning supplies locked in the garage. First aid kit was completed with bandages, tweezers, scissors, and thermometer located in the hallway. LPA observed required Licensing postings posted on facility walls. LPA observed required furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. The hot water temperature was measured in residents' bathroom at 104.6 degree Fahrenheit. LPA observed fire detectors and carbon monoxide at the facility.

Component III presentation conducted with Administrator, Diana Kurtz.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Application Bureau (CAB) and final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with Administrator, Diana Kurtz, via telephone and a copy of this report will be provided to the facility via email. Report is to be signed and returned to LPA via email.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2021
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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