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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210072
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:04:15 AM

Document Has Been Signed on 11/10/2022 10:04 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OLYMPIC HOMEFACILITY NUMBER:
419210072
ADMINISTRATOR:ANTOLIN G. UCOLFACILITY TYPE:
735
ADDRESS:2415 OLYMPIC DRIVETELEPHONE:
(650) 873-3998
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 5DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Caregiver, Michael PonceTIME COMPLETED:
10:15 AM
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On November 10, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Caregiver, Michael Ponce and explained the purpose of the visit. Caregiver was able to provide LPA screening log documentation for staff, visitors, and residents.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 bedrooms and 2 full bathrooms. LPA observed 3 resident bedrooms to be shared rooms with beds 6ft apart or 3ft head-to-toe. LPA observed one bedroom to be a staff room. LPA observed 2 full bathrooms and advised caregiver to ensure both bathrooms have a hand-washing sign, trash can with a fitted lid, and to substitute the hand-towels for paper towels. Bathrooms were clean and odor-free. Extra linen was observed to be present.

LPA toured the living room and dining rooms and observed it to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. During the visit, there were 5 residents observed. 2 staff were observed with face masks. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. LPA advised Caregiver to remove hand-towels. Sharps were stored appropriately an inaccessible to resident and medications were observed to be locked.

LPA toured the garage and observed chemicals and toxins to be locked. In addition, LPA observed washer and dryer to be in good working condition and observed extra food supply present. 30-day PPE supply was present. First aid kit was observed to be completed.

Infection control practices are observed: entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

LPA requests the following forms to be submitted to CCLD by November 17, 2022:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan
-LIC400 Resident Cash Resources
-Administrator Certificate

No citations will be issued during this visit. Report is reviewed with Caregiver and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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