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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601054
Report Date: 05/04/2022
Date Signed: 05/04/2022 05:42:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220426142346
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: DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Marjorie Kate Pasaymau and Olivia De GuzmanTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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RSO who is not a client allegedly resides, is present, and/or has contact that may pose a risk to the health and safety of clients in care
INVESTIGATION FINDINGS:
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Based on evidence obtained during the course of this investigation, the Department has substantiated that an individual who has been convicted of a crime for which registration as a Registered Sex Offender (RSO) is required, is residing at facility or has presence/contact that may pose a risk to the health and safety of the clients in care at a facility licensed by the Department. This is a factual determination based on all the facts and circumstances of the case.

Deficiency of the California Code of Regulations is cited on a following page, and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20220426142346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited
CCR
87355(a)
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CRIMINAL RECORD CLEARANCE
The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.
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Staff #1 1 was served with letter of immediate exclusion and a copy was also provided to facility administrator on 4/25/22.
Plan/proof of correction shall be submitted to CCLD BY DUE DATE.
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Based on the Department's investigation, the presence of staff #1 in facility with client contact posed an immediate health, safety or personal rights risk to clients in care.
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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) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2