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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600965
Report Date: 08/23/2024
Date Signed: 08/23/2024 01:48:00 PM


Document Has Been Signed on 08/23/2024 01:48 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
SAN BRUNO RO, 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:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator - Olivia De GuzmanTIME COMPLETED:
02:00 PM
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On 08/23/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Olivia De Guzman and explained the purpose of today's inspection. There are currently five residents in the facility, one is currently in the hospital. No residents are on hospice at this time. One resident uses oxygen.

This is a single level facility, licensed for residents age range of 60 years and over all of which may be non-ambulatory with a hospice waiver for three residents. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. To the rear of the facility is a garage that is not part of the facility and the licensee/administrator does not have access to. There is a two level private dwelling located at the rear of the facility that does not have access into the facility. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen cabinet adjacent to the sink. Medications are also locked in a cabinet adjacent to the sink. Perishable and non-perishable food items are observed as in place. There are two additional refrigerators and freezer for resident food supplies located in a staff room. First aid kits are observed as complete with required items and stored at time of visit at the end of the hallway on a table with PPE. LPA observed that there are two fire extinguishers in place inspected on 05/23/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull stations are located at the front door and rear side door of the facility. Facility is not equipped with fire sprinklers. Laundry area is also observed as fully operational, and lockable, at the end of the hallway. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 07/13/2024. Water temperature is measured at 107F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the laundry area at the end of the hall. A fire panel is present and located in the same close as the linens. An inspection tag is on the panel but LPA cannot determine the date of last inspection.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: OLIVIA'S CARE HOME
FACILITY NUMBER: 415600965
VISIT DATE: 08/23/2024
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LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. There are two staff rooms at the rear of the facility marked as "Private". Resident linen supplies are observed as in place stored in a hallway closet. There is one common full bathroom located in the hallway. Shower floor is equipped with non-skid mat. During today's inspection LPA reviewed four resident files which are current and three staff files which are current. Training hours are on file as current for staff. Medications are inspected and are accurate to what is listed on centrally stored medication and destruction record.

The following updated forms are requested to be submitted to CCLD by 08/30/2024:

• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

No citations issued on this day.

Report is reviewed with Olivia De Guzman and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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