Community Care Licensing

SUPERVISOR'S NAME: Julio Montes TELEPHONE: (650) 266-8811 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022

Document Has Been Signed on 08/04/2022 05:38 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/04/2022 10:21 AM

FACILITY NAME: OLIVIA'S CARE HOME II	FACILITY NUMBER: 415601054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2022

Type A

Section Cited

CCR

87355(e)(1)

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with administrator Olivia De Guzman, the licensee did not comply with the section cited above, as 3 out of 4 on-site staff do not have criminal record clearance and association with facility, which poses an immediate health, safety or personal rights risk to persons in care. Staff #2 and #3 are present in facility with clients, but do not have criminal record clearance nor association to this facility. Administrator stated that they arrived to facility on 7/24/22 and have not started observing clients yet. Staff #1 has criminal record clearance, but is not associated to this facility. Administrator to submit Criminal Record Clearance Transfer Request Form and photo ID to CCLD to transfer criminal record for staff #1. Civil penalty of $200 is issued to assess immediate $100/person for staff #2 and #3.
	POC Due Date: 07/26/2022
	Plan of Correction
1 2 3 4	Administrator to submit plan of correction to CCLD for removal of staff #2 and #3, or proof of criminal record clearances.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Jackie Jin TELEPHONE: (650) 266-8811 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022

Document Has Been Signed on 07/25/2022 05:53 PM - It Cannot Be Edited

FACILITY NAME: OLIVIA'S CARE HOME II	FACILITY NUMBER: 415601054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2022

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with administrator, the licensee did not comply with the section cited above, as 1 out of 2 staff does not have health screening and TB test result on file, which poses a potential health, safety or personal rights risk to persons in care. Staff #1 does not have health screening nor TB test result, but has worked for over one month.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	Copy of health screening and TB test result for staff #1 to be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: Julio Montes TELEPHONE: (650) 266-8811 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022

Document Has Been Signed on 07/25/2022 05:53 PM - It Cannot Be Edited

FACILITY NAME: OLIVIA'S CARE HOME II	FACILITY NUMBER: 415601054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2022

Type B

Section Cited

CCR

87468.1(a)

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with administrator, the licensee did not comply with the section cited above, as daily log of staff and clients' COVID signs, symptoms and temperature is not being maintained. The last date that this information was recorded is 3/26/22. This poses a potential health, safety or personal rights risk to persons in care. Civil penalty of $250 is assessed, as this is a repeat violation. Deficiency was cited on 7/30/21 during annual inspection.
	POC Due Date: 07/26/2022
	Plan of Correction
1 2 3 4	Daily civil penalty of $100/day will accrue until plan of correction is submitted to CCLD and approved by LPA.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Julio Montes TELEPHONE: (650) 266-8811 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022