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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601079
Report Date: 10/05/2022
Date Signed: 10/05/2022 10:17:19 AM

Document Has Been Signed on 10/05/2022 10:17 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OLIVIA'S CARE HOME IIIFACILITY NUMBER:
415601079
ADMINISTRATOR:DE GUZMAN, PATRICIAFACILITY TYPE:
740
ADDRESS:317 W 20TH AVENUETELEPHONE:
(650) 638-0352
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
10/05/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Caregiver, Annalissa CondezTIME COMPLETED:
10:25 AM
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On October 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced collateral investigation visit to deliver findings to a complaint received under previous licensee. LPA met with Caregiver, Annalissa Condez and explained the purpose of the visit.

LPA explained that the visit was in relation to complaint being received under the previous licensed facility, Rosie's Home For The Aged who used to be licensed at this facility's current address.

Report is reviewed with Caregiver, Annalissa Condez and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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