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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601090
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:33:07 PM

Document Has Been Signed on 12/22/2021 03:33 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:OLYMPUS PLACEFACILITY NUMBER:
415601090
ADMINISTRATOR:GUEVARRA, EDITHAFACILITY TYPE:
735
ADDRESS:2470 OLYMPUS PLACETELEPHONE:
(650) 892-1083
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 1DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Paula Jane Garcia and ARnold GonzalesTIME COMPLETED:
03:45 PM
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LPA Audrey Jeung toured facility and grounds, located at 2470 Olympic Drive, SSF. This one level home consists of 4 client bedrooms and 2 shared bathrooms, kitchen, dining and living rooms. Grab bars are not yet installed for 2 toilets and 2 showers, as required for non-ambulatory licensure. There is a wood deck in the rear and sides of building. Facility serves Level 4 Regional Center clients with medical and behavioral needs. No accessible bodies of water or fire safety hazards are observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There is one resident present, and 1 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is checked. Paula Jane Garcia is a certified ARF administrator (x 1/2023) that oversees facility operations with Editha Guevarra.

The following licensing forms/information are requested to be submitted to CCLD by 1/5/21:

- LIC 308 Designation of Administrative Responsibility
- LIC 500 Personnel Report
- LIC 808 COVID-19 Mitigation Plan
- LIC 200 Application (to provide correct street address and phone numbers)

Updated Emergency Disaster Plan (LIC610) is given to LPA today.
Annual fee is overdue and amount of $681 is due and payable.

Deficiency of the CA Code of Regulations, Title 22, Division 6, is cited on a following page. See also Technical Advisory note.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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 12/22/2021 03:33 PM - It Cannot Be Edited


Created By: Audrey Jeung On 12/22/2021 at 03:03 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: OLYMPUS PLACE
FACILITY NUMBER: 415601090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
FIXTURES, FURNITURE, EQUIPMENT AND SUPPLIES
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F.

This requirement is not met as evidenced by thermometer reading of 127 degrees in small bathroom.
Deficient Practice Statement
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Based on thermometer reading in small bathroom, the licensee did not comply with the section cited above, as hot water temperature tested at 127 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
Hot water temperature log maintained by staff recorded hot water temperature between 113 and 131 degrees from 12/14/21 to present.
POC Due Date: 12/23/2021
Plan of Correction
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Hot water temperature shall be lowered and maintained between 105 and 120 degrees at all times. Proof of correction to be submitted to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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