415601171-7-11-2024-14-AS-AJEG-D73S4A-20240711133226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601171
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:32:32 PM

Document Has Been Signed on 07/11/2024 01:32 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	OLIVIA'S CARE HOME IV		FACILITY NUMBER:	415601171
ADMINISTRATOR:	GUZMAN, PATRICIA DE		FACILITY TYPE:	740
ADDRESS:	2836 FLORES ST.		TELEPHONE:	(415) 613-0314
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	12	CENSUS: 10	DATE:	07/11/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Patricia De Guzman		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Applicant Premier Home LLC has applied for RCFE licensure for 12 non-ambulatory elderly clients in 10 rooms. Fire clearance has been approved. Facility is currently licensed and operating under the name Maria's Home for the Elderly #415601025. There are 2 residents who currently receive hospice care. On 5/9/24, LPA Jeung toured facility and grounds of this one level facility. There are 10 bedrooms--each with private half bathrooms--2 staff rooms--1 with half bathroom--full bathroom with 2 shower enclosures, living room/dining room, and kitchen. There are 3 beds in 1 staff room and one bed in the small staff room. Clothes washer and dryer are located on lower level, where there is an additional storage room and 1-car garage. Three other garages are not accessible, and belong to property owner. There is a wood ramp on the south, west (south) and part of north sides of the building, as well as small backyard. Above the facility, there is a separate living unit with a separate entrance, that is not part of RCFE. Medications and toxins are secured in locked cabinets in dining room armoire and stairwell next to kitchen, respectively. Hot water temperature is tested at 103 degrees in common bathroom. Food preparation and service items are present, as well as perishable fruits, vegetables and protein. Supplies of bed and bath linens and hygiene products are observed. First aid kit is complete. Patricia De Guzman is a certified RCFE administrator (x 11/25). LPA Jeung reviewed corrections of deficiencies observed during initial pre-licensing tour on 5/9/24 and citations issued to existing facility, Maria's Home for the Elderly #415601025. Due to unreported CoVID, initial pre-licensing visit was suspended. - Continued on following page -

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OLIVIA'S CARE HOME IV	FACILITY NUMBER: 415601171
	VISIT DATE: 07/11/2024

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The following items are observed and must be addressed prior to licensure:

1. A set of keys--including all resident units, facility vehicles, all exit doors, all cabinets, cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies--must be available to staff on each shift for use during an evacuation. (1569.695)
2. Emergency Disaster Plan (LIC610E) must be updated to include corrected utility shut off and fire extinguisher locations. (Section 87212 Emergency Disaster Plan)
3. There is an insufficient 7-day supply of canned fruit (Section 87555 General Food Service).

LPA to be contacted upon completion of the above 3 items.

Facility phone number is 650/458-3265.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

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