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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601171
Report Date: 01/30/2024
Date Signed: 01/30/2024 11:58:01 AM


Document Has Been Signed on 01/30/2024 11:58 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:OLIVIA'S CARE HOME IVFACILITY NUMBER:
415601171
ADMINISTRATOR:GUZMAN, PATRICIA DEFACILITY TYPE:
740
ADDRESS:2836 FLORES ST.TELEPHONE:
(415) 613-0314
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:12CENSUS: 9DATE:
01/30/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Patricia De GuzmanTIME COMPLETED:
11:52 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 12
Census (if any clients in care): 9
COMP II Participants: Patricia De Guzman (Corporate Board Member & Administrator)
Interview Method: Virtual interview via Microsoft Teams


On January 30, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 657-7817
LICENSING EVALUATOR NAME: Diamond LawTELEPHONE: (916) 657-3571
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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