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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601079
Report Date: 02/27/2025
Date Signed: 02/27/2025 01:51:59 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/27/2025 01:51 PM - 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 IIIFACILITY NUMBER:
415601079
ADMINISTRATOR/
DIRECTOR:		DE GUZMAN, PATRICIAFACILITY TYPE:
740
ADDRESS:317 W 20TH AVENUETELEPHONE:
(650) 638-0352
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Patricia De GuzmanTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 02/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with staff person Neil Magdaraog today and explained the purpose of today's visit. Currently there are 2 staff present and 5 residents. All residents are in their rooms by choice. Around 11:16pm the administrator Patricia De Guzman arrived and met with LPA.

This is a two level facility but the upstairs of the facility is a private rental. There is also another private rental in the backyard of the facility in a disconnected smaller home. Facility is licensed for age range 60 and over all of which must be ambulatory. Facility is cleared for 3 hospice residents. 1 resident is on hospice as of today's visit. The facility operates on the ground floor of this address. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Laundry area is in the garage and is fully functional. Knives are locked in the kitchen drawer adjacent to the stove/range. Medications are locked in the island area of the kitchen. Toxic chemicals and cleaning supplies are observed in the hallway closet. PPE are in place as stored in the dining room area in a cabinet and garage. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. LPA observed a fire extinguisher in the kitchen with an inspection tag of 05/23/2024 which is charged and ready for use.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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 III
FACILITY NUMBER: 415601079
VISIT DATE: 02/27/2025
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Facility has one common full bathroom for resident use. All resident rooms are also equipped with half bathrooms as well. Shower floor is equipped with non-skid flooring. Based on review of all resident files, and medications all items are current and logged accurately. Staff files are reviewed and are current. Emergency disaster drill records are observed as current being conducted quarterly. Last drill was conducted on 01/30/2025. Administrator certificate is observed as current expiring 11/27/2025 per online review. A physical certificate was never received by the administrator.

The following updated forms are being requested to be received by 03/06/2025:

• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

There are no citations issued during today's inspection visit. Technical violations are issued on the attached two pages.

Report is reviewed with Patricia De Guzman and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
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