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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601054
Report Date: 07/30/2021
Date Signed: 08/05/2021 06:07:37 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 HOME IIFACILITY NUMBER:
415601054
ADMINISTRATOR:GUZMAN, OLIVIA DEFACILITY TYPE:
740
ADDRESS:48 WEST 39TH AVETELEPHONE:
(415) 609-4688
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mark Pasay and Olivia De GuzmanTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, each with a half bathroom, and a staff bedroom on the main level, plus 1 common full bathroom. There is an attic that is accessed from staff room by pull down ladder, with 3 rooms and a small room that appears to be an unfinished bathroom. There is a 2 car garage that is used for storage, and laundry. No accessible bodies of water are present. 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. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, in addition to health screenings, TB test results, and valid first-aid training. 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 8/6/21:

• LIC 999 Facility Sketch, including attic
• Current liability insurance

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are 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: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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 3
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 II
FACILITY NUMBER: 415601054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
FIRE SAFETY
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 the attic rooms are used by staff for sleeping, which poses an immediate health, safety or personal rights risk to persons in care.
As per fire clearance issued in May 2019, attic can only be used for storage. There are 3 rooms; one has box spring and mattress on floor; the other 2 rooms have mattresses or futon on the floor, and personal items, shoes, clothes hanging on rods and lamps and other items plugged into electrical outlets. It appears there are 4 beds being used in 2 rooms.
POC Due Date: 08/02/2021
Plan of Correction
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Attic rooms will be vacated and will not be used for sleeping, per facility's fire clearance.
Proof of correction to be submitted to CCLD BY DUE DATE.
Failure to comply may result in denial of fire clearance.
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: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 II
FACILITY NUMBER: 415601054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1
PERSONAL RIGHTS
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
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 absence of records documenting staff and clients' Covid signs, symptoms and temperature, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2021
Plan of Correction
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Proof of correction to be sent to CCLD BY DUE DATE, which shall include copies of staff and client logs to be used to record daily temperatures and Covid signs and symptoms.
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: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3