<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600965
Report Date: 08/12/2022
Date Signed: 08/12/2022 05:11:59 PM


Document Has Been Signed on 08/12/2022 05:11 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
SF COASTAL AC/SC, 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:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Eva Zita and Olivia De GuzmanTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms--each with private half bathrooms--and 2 staff bedrooms; rear staff room has one bed and the other has a bunk bed 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 who has criminal record clearance. 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. Two residents are receiving hospice services. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Olivia De Guzman is a certified RCFE administrator (x 6/22) that oversees facility operations. Copies of training certificates for 40 hours is observed, as well as check register which shows payment to CDSS for renewal of administrator certificate.


Proof of current Liability Insurance is requested to be sent to CCLD by 8/19/22.

Updated Personnel Report (LIC500) is given to LPA today.

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. Facility is operating in substantial compliance.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022
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 1