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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601090
Report Date: 11/01/2023
Date Signed: 11/01/2023 12:27:51 PM

Document Has Been Signed on 11/01/2023 12:27 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: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:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Paula GarciaTIME COMPLETED:
11:45 AM
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On 11/1/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with caregiver Laarni Ocampo and Administrator, Paula Garcia came shortly after. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms and kitchen area. LPA observed one resident waiting to be picked for a program and two residents resting in their rooms. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 118 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked and inaccessible to residents. Food supply in was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility.

Four resident records and four staff records were reviewed. Resident’s PNI money was counted and all accounted for. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans.

Centrally stored medication was locked in the medicine cart and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

Licensee submitted the following: LIC 500 Personnel Report, LIC 400 & Control of Property.

No deficiencies are cited at this time. Report is reviewed and copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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