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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600965
Report Date: 06/28/2021
Date Signed: 06/28/2021 02:53:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OLIVIA'S CARE HOMEFACILITY NUMBER:
415600965
ADMINISTRATOR:DE GUZMAN, OLIVIAFACILITY TYPE:
740
ADDRESS:2087 ISABELLE AVETELEPHONE:
(650) 345-3051
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Olivia De GuzmanTIME COMPLETED:
03:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms--each with private half bathrooms--and 2 staff bedrooms for 2 staff. There is a room that is not accessible in the rear of building--on left side--that administrator advised is occupied by an independent renter. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff, plus the administrator. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Olivia De Guzman is a certified RCFE administrator (x 6/22) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 7/6/21:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• Proof of current Liability Insurance


Updated Emergency Disaster Plan (LIC610E) and Personnel Report (LIC500) are given to LPA today.


Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OLIVIA'S CARE HOME
FACILITY NUMBER: 415600965
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as LPA was not Covid screeened upon entrance to facility, which poses a potential health, safety or personal rights risk to persons in care.
A sign-in policy has not been enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing). This practice has a health and safety impact that includes, but is not limited to personal rights, and reporting requirements.
POC Due Date: 07/01/2021
Plan of Correction
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Proof of correction shall be submitted to CCLD BY DUE DATE, which will include copy of visitor sign in sheet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2021
LIC809 (FAS) - (06/04)
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