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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210072
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:02:53 PM

Document Has Been Signed on 06/19/2024 03:02 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:OLYMPIC HOMEFACILITY NUMBER:
419210072
ADMINISTRATOR/
DIRECTOR:
ANTOLIN G. UCOLFACILITY TYPE:
735
ADDRESS:2415 OLYMPIC DRIVETELEPHONE:
(650) 873-3998
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 5DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:49 PM
MET WITH:Antolin Ucol & Elsa CabalangTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On 6/19/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Antolin Ucol & Direct Care Staff Elsa Cabalang. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. No residents are in the facility. Residents are currently sleeping in bedrooms & living rooms. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked and inaccessible to residents. Food supply in kitchen was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill will is done every quarter.

Five resident records and five staff records were reviewed. Resident’s PNI money was counted and all accounted for. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR & CPI certifications on file. Resident records were reviewed and were observed to be complete. Centrally stored medication was locked. All medication was labeled and sorted by resident name. All medication logs are complete and updated.

LPA received LIC 500.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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