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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601171
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:14:42 PM


Document Has Been Signed on 05/09/2024 02:14 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 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: 10DATE:
05/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jackie WaughTIME COMPLETED:
02:15 PM
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LPA Jeung met with staff and toured facility, including at least 2 private rooms where COVID residents reside. There are no signs posted on doors, no PPE station outside of rooms, only ONE N95 mask available for staff, and LPA was not informed of COVID until AFTER entire facility was toured.

This visit is suspended and report will be forwarded to applicant.

Facility is not ready for licensure.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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