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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601054
Report Date: 07/09/2024
Date Signed: 07/09/2024 11:43:58 AM

Document Has Been Signed on 07/09/2024 11:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OLIVIA'S CARE HOME IIFACILITY NUMBER:
415601054
ADMINISTRATOR/
DIRECTOR:		GUZMAN, OLIVIA DEFACILITY TYPE:
740
ADDRESS:48 WEST 39TH AVETELEPHONE:
(415) 609-4688
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator/Licensee - Olivia De GuzmanTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 07/09/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with caregivers Alizza and Generoso and explained the purpose of today's visit. There is 2 staff and 6 residents present. Around 10:50am during the visit the administrator/licensee Olivia De Guzman arrived and met with LPA.

LPA was allowed entry into the facility. This is a single level facility approved for 2 hospice residents and all may be non-amblatory. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the refrigerator. Medications are observed to be locked in a cabinet adjacent to the refrigerator. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place inspected 05/0/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. The facility has fire sprinkler systems through out. PPE and additional food supplies are observed as in place. Laundry area is also observed in the garage as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 05/23/2024. Water temperature was measured at 107F.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: OLIVIA'S CARE HOME II
FACILITY NUMBER: 415601054
VISIT DATE: 07/09/2024
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LPA observed rooms 2, 5, and 6 all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. All resident rooms are equipped with half baths. Water temperature taken in room 6 is measured at 107F. There is a full bathroom with walk in shower area for resident use. Water temperature is tested at 105F in this shower room/full bathroom. Shower floor uses non-skid mat when shower is in use. Resident linen supplies are observed as in place in a hallway closet. Cleaning supplies are also observed as locked in a hallway closet. There is a staff room, room #1 where there is an attic that is accessed by pull down ladder. Per licensee and observations were made. There are no beds, or staff residing in the attic space. It is now housing resident incontinence supplies.

LPA reviewed 2 client files and also reviewed 3 staff files on this day. Per resident files reviewed R2 with dementia does not have an updated physicians report on file. Last report on file is dated 04/05/2019. This poses a potential health and safety risk. Per staff files reviewed all files were current with training and CPR/First Aid. P&I is not handled by the facility. Client medications are inspected and are current/logged in centrally stored medication record. Administrator certificate is observed as current expired on 06/26/2024 but according to the licensee she submitted payment and has the training hours completed.

The following updated forms are requested to be submitted to CCLD by 07/16/2024:

• Copy of updated Administrator Certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property

Citation issued on this day on the attached. Report is reviewed with Noralee and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2024 11:43 AM - It Cannot Be Edited


Created By: Jaime Vado On 07/09/2024 at 11:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited

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87705(c)(5) - Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This regulation has not been met as evidenced by:
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Based on resident file reviews, LPA observed that R2 does not have a current physicians report on file. The last physician report is dated 04/05/2019. This posese a potential health and safety risk to the resident 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:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
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