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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601054
Report Date: 08/09/2021
Date Signed: 08/09/2021 05:26:00 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:
08/09/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Irine Aquino & Olivia De GuzmanTIME COMPLETED:
05:30 PM
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LPA Jeung inspected attic in response to citation issued on 7/30/21 during annual inspection, and plan of correction submitted on 8/2/21 by administrator that attic rooms have been vacated and will not be used for occupancy. All personal items--including clothing and electronics--and furnishings have been removed from 3 rooms. Mattresses and box springs are stripped and leaning against walls. It is noted that staff room on ground level where attic ladder is accessed has been modified, in that a wall has been removed. It is now consistent with the facility sketch submitted in 2019 upon licensure.

Acknowledgement of correction is issued today--1 page.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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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