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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 10:15:30 AM

Document Has Been Signed on 10/05/2022 10:15 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:Required - 1 YearUNANNOUNCEDTIME 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 annual infection control inspection. LPA met with Caregiver, Annalissa Condez, and explained the purpose of the visit. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA was screened at entry point and Caregiver was able to provide LPA with screening log documentation for residents, staff, and visitors.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a double story home, however the second story is being rented out. The first story is observed to have 7 bedrooms, 6 of which are private resident rooms and 1 is utilized as a staff room. Each bedroom has their own half-bathroom. There is one shared bathroom observed. LPA observed hand-washing signs in all bathrooms. LPA Charitra advised caregiver to ensure that there are no bar soaps or hand-towels present in the shared bathroom and ensure that there are paper-towels and liquid soap present instead. In addition, LPA advised caregiver to ensure all trash-cans have a fitted lid. LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. COVID-19 signage was posted throughout the facility. Extra linen was observed to be present.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps and medications were observed to be locked and inaccessible to residents. LPA advised caregiver to remove hand towels. Kitchen was observed to be equipped with liquid soap and paper-towels, with hand-washing signs.

LPA toured the garage and observed chemicals and toxins to be locked. In addition, LPA observed washer and dryer to be in good condition and observed extra food supply present. 30-day PPE supply was present. There is a staff room in the garage. According to the Caregiver, the garage stays locked at all times and it is inaccessible to residents. Staff first aid cards were observed to be current.

Infection control practices are observed: COVID signage posted throughout the facility, entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

No citations will be issued during this visit. Report is reviewed with Caregiver, Annalissa Condez and a copy is provided.

LPA requests the following to be submitted to CCLD by 10/12/2022:
-LIC308 Designation of Administrative Organization
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
-Administrator Certificate
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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