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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210072
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:00:05 PM

Document Has Been Signed on 10/29/2024 12:00 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: 0DATE:
10/29/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Adora AnchetaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 10/29/2024, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee, Adora Ancheta.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, April Cowan, Licensing Program Analysts, Grace Donato, Audrey Jeung and Murial Han, Administrators Kelly Ancheta & Rochelle Rivera, GGRC QA Manager, Skylar Spencer.
 
During non-compliance meeting, the following violation was discussed, Personnel Requirements, Administrator Qualifications and Duties & Personal Rights.

During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation.  Licensee was provided the link below for resources and guidance to improve facility operations: 
  
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

Report was reviewed with Licensee/Administrator and a copy of this report is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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