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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601079
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:23:10 PM

Document Has Been Signed on 04/28/2022 03:23 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
CCLD Regional Office, 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: 6DATE:
04/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lissa Condez and Olivia De GuzmanTIME COMPLETED:
03:30 PM
NARRATIVE
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During complaint investigation, a deficiency of the California Code of Regulations, Title 22 is observed and cited on a following page.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 03:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 04/28/2022 at 02:55 PM
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 III
FACILITY NUMBER: 415601079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
87412(a)(13)(B)

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PERSONNEL RECORDS
Each personnel record shall contain, for employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance, documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).
This requirement is not met, as staff NDC does
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Plan of correction to be submitted to CCLD by DUE DATE
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not maintain criminal record clearance and association to this facility. Licensee failed to ensure that correct license number is recorded on Live Scan service form, so NDC's criminal record clearance is associated to another facility, as verified in Guardian. This poses a potential health and safety threat to residents in care. Administrator advised that NDC will be employed only until 4/30/22.
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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 Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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