415600965-4-29-2022-14-AS-CSMH-CMQPNK-20230103102804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600965
Report Date: 04/29/2022
Date Signed: 04/29/2022 07:22:25 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220421143553

FACILITY NAME:	OLIVIA'S CARE HOME		FACILITY NUMBER:	415600965
ADMINISTRATOR:	DE GUZMAN, OLIVIA		FACILITY TYPE:	740
ADDRESS:	2087 ISABELLE AVE		TELEPHONE:	(650) 345-3051
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Eva Zita and Olivia De Guzman		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

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Untrained staff are administering insulin to residents

INVESTIGATION FINDINGS:

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LPA Jeung met with client, staff and administrator, who is also a registered nurse. LPA also reviewed client files. Per MD reports, only one client is diagnosed as diabetic, although there are 2 clients who are tested for blood sugar levels and require insulin injections. Both clients' MDs have documented that they may perform self glucose tests and self inject insulin with assistance from staff. LPA observed blood sugar testing and insulin administration logs for clients #4 and #5, as well as prescribed insulin pens--Lantus and Admelog for client #4 and Humalog and Lantus for client #5. LPA observed client #5 use a glucometer to prick her fingertip with assistance from staff Zita, and inject insulin in her stomach using an insulin pen that contains up to 20 units of insulin.

Based on this investigation, this complaint allegation is determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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