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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601090
Report Date: 08/08/2023
Date Signed: 08/08/2023 10:48:25 AM

Document Has Been Signed on 08/08/2023 10:48 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:OLYMPUS PLACEFACILITY NUMBER:
415601090
ADMINISTRATOR:GUEVARRA, EDITHAFACILITY TYPE:
735
ADDRESS:2470 OLYMPIC DRIVETELEPHONE:
(650) 892-1083
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
08/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Arnold GonzalesTIME COMPLETED:
11:15 AM
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On 8/8/2023, Licensing Program Analyst (LPS) Grace Donato conducted an unannounced case management visit. LPA met with Direct Support Professional, Arnold Gonzales. LPA explained the purpose of the visit.

On 6/30/23, facility submitted an incident report regarding a resident given one 5 mg CBD gummies. These gummies were brought to the facility without prescription from PCP.

Based on interview and records review, facility was not able to obtain prescription for the CBD gummies. When the 3 bottles were brought to the facility by the responsible party (RP), facility staff counted the open bottle and recorded to have 19 pcs, with the 1 already given when they were at the day program. The other 2 bottles are sealed. On 6/30/23, when RP visited the resident, all bottles were returned.

Facility has followed regulations regarding medications.

No citations are issued at this time.

Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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