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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601171
Report Date: 08/18/2025
Date Signed: 08/18/2025 02:48:38 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/18/2025 02:48 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/
DIRECTOR:		GUZMAN, PATRICIA DEFACILITY TYPE:
740
ADDRESS:2836 FLORES ST.TELEPHONE:
(415) 613-0314
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 12CENSUS: 11DATE:
08/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Patricia De GuzmanTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 08/18/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Patricia De Guzman and explained the purpose of today's inspection. There are currently 11 residents in the facility and 4 staff persons working on this day.

This is a single level facility, licensed for residents age range of 60 years and over all of which may be non-ambulatory with a hospice waiver for 5 residents and a waiver for 4 bedridden. There are 4 hospice residents at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. The facility itself is the lower level of the home. There is locked access to the facility from the upper floor. The upper floor is privately owned by the landlord of the entire physical plant. The facility garage is on the lower level. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove/range. Medications are locked in a cabinet located in the dining room area. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator for resident food supplies located in the garage along with incontinence supplies and PPE. First aid kit is observed as complete with required items and stored in the medicine cabinet. LPA observed that there are three fire extinguishers in place inspected on 01/07/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull station is located at the front door of the facility. Facility is fully equipped with fire sprinklers. Laundry area is also observed as fully operational, and locked in the garage area of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 05/10/2025. Water temperature is measured at 105F in the common bathroom located at the end of the hall. Cleaning supplies are observed to be locked an not accessible to residents A fire panel is present at the end of the hall with an inspection date of 07/05/2023. Linens are observed as in place in a hallway closet.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/18/2025
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LPA observed resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. All resident rooms contain a half bathroom. There are two staff rooms as well which are labeled. There is one common full bathroom located in the hallway. Shower floor does have non-skid mats present for use. During today's inspection LPA reviewed 5 resident files which are current and 5 staff files which are current. Training hours are on file as current for staff. Medications are inspected and are accurate to what is listed on centrally stored medication and destruction record. Administrator certificate is current expiring on 11/27/2025.

The following updated forms are requested to be submitted to CCLD by 08/25/2025:

• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule

No citations issued on this day.

Report is reviewed with administrator Patricia De Guzman.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC809 (FAS) - (06/04)
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