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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601171
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:41:02 PM


Document Has Been Signed on 08/08/2024 12:41 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 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:
08/08/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Patricia De GuzmanTIME COMPLETED:
12:45 PM
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LPA Jeung met with administrator to review RCFE Component III Orientation. The following topics were discussed:

- Operating Requirements
- Physical Environment
- Personnel Requirements
- Resident Records
- Reporting Requirements
- Health Related Services and Conditions
- Dementia Care

Pre licensing inspection was conducted on 7/11/24 and licensee has addressed issues identified during that inspection to comply with Title 22 regulations.

Facility meets physical plant requirements for licensure of 12 bed Residential Care Facility for the Elderly.
Immediate licensure is recommended, pending final approval by Central Applications Bureau.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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