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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601079
Report Date: 04/08/2024
Date Signed: 04/08/2024 06:13:17 PM


Document Has Been Signed on 04/08/2024 06:13 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
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: 6DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Jayron Espanto & Olivia De GuzmanTIME COMPLETED:
06:15 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms and staff room--all with half bathrooms--on ground level, as well as living/dining room. There is a staff room on lower level adjacent to garage, and a 2-bedroom rental unit on 2nd floor; this apartment is accessed through garage. In addition, there is an accessory dwelling unit in backyard, that has a separate address. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete and maintained. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. An updated Disaster and Mass Casualty Plan is available. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Olivia De Guzman (x 6/24) is a certified RCFE administrator that oversees facility operations.
Staff records, including training, will be reviewed at a later date.

As per legislation, effective 1/1/2015, the following information is posted: 1) PUB474, pertaining to resident councils, per AB1572; 2) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 3) CCLD Hotline information, per SB895.

Administrator is requested to submit the following updated information/forms to CCLD by 4/22/24:
- Administrative Organization (LIC309)
- Personnel Report (LIC500)

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. See Advisory Notes issued--5 pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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