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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601054
Report Date: 08/04/2022
Date Signed: 08/04/2022 05:33:53 PM


Document Has Been Signed on 08/04/2022 05:33 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 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:
08/04/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Kate PasaymauTIME COMPLETED:
05:45 PM
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LPA Jeung met with staff and spoke with administrator by phone regarding deficiencies and civil penalties issued on 7/25/22 during annual inspection, for which corrections have not yet been submitted. Per the Facility Evaluation Report issued on 7/25/22, "daily civil penalty of $100/day will accrue until plan of correction is submitted to CCLD and approved by LPA." Administrator Olivia De Guzman overlooked submitting proof of correction to LPA. However, LPA observed that daily temperature and COVID symptom checks are logged for staff and residents, starting 7/26/22. See acknowledgement of correction and additional civil penalty assessment--$100 for 7/26/22.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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