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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210072
Report Date: 07/21/2023
Date Signed: 07/21/2023 01:40:01 PM

Document Has Been Signed on 07/21/2023 01:40 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
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:
07/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Co-Administrator Kelly Ancheta TIME COMPLETED:
02:00 PM
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On July 21, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Grace Donato conducted an unannounced case management visit to follow up on a visit made on 11/10/2022. LPAs met with Co-Administrator Kelly Ancheta and Administrator, Antolin Ucol and explained the purpose of the visit.

On 11/7/22, the Licensee reported that Staff 1 (S1) was found deceased in the facility garage. The Department investigated this case and found that there was neglect and lack of supervision on the residents as a result of S1 passing away while on duty. In addition, the investigation found that the residents were not attended to or checked on during the overnight shift. Based on the interviews conducted during the investigation, it was unknown to other staff and licensee that the staff had passed away.

Furthermore, LPA interviewed the Administrator, Antolin Ucol and reviewed resident files. Based on file reviewed, there is a resident (R1) who is required to be checked on and changed at night due to R1 being incontinent. According to Administrator, there was no staff plan of operation in monitoring the staff working NOC shift. In addition, according to the administrator, staff working NOC shift did not document and/or track whether R1 was being checked on or changed throughout the night.

Furthermore, based on interview conducted with the Administrator, it was indicated that from November 2022 when S1 passed away till June 2023, there has not been a NOC shift staff member on duty.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties.

Report is reviewed with Co-Administrator, Kelly Ancheta and a copy is provided with appeal rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 07/21/2023 01:40 PM - It Cannot Be Edited


Created By: Komal Charitra On 07/21/2023 at 12:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OLYMPIC HOME
FACILITY NUMBER: 419210072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2023
Section Cited
CCR
85065(b)

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85065 Personnel Requirements:
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to provide an updated LIC500 to LPA by 7/22/2023.
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Based on interviews conducted and information collected, the administrator indicated that from November 2022 when S1 passed away to June 2023, there has not be a NOC shift staff member to ensure R1 receiving care and supervision to meet client’s incontinent needs.

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Type A
07/22/2023
Section Cited
CCR85064(j)(2)

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85064 Administrator Qualifications and Duties: (j) The administrator shall perform the following duties: (2) Development of an administrative plan and procedures to define lines of responsibility, workloads, and staff supervision.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to ensure NOC shift staff are documenting care that is provided to R1. Licensee/Administrator to submit a plan in writing addressing how he/she will monitor NOC shift staff on duty
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Based on interviews conducted, records reviewed, and information collected, the administrator failed to ensure that there was a NOC shift staff member on duty to provide care and supervision to R1. In addition, Administrator failed to maintain a staff plan of operation in monitoring the staff working NOC shift.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 07/21/2023 01:40 PM - It Cannot Be Edited


Created By: Komal Charitra On 07/21/2023 at 12:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OLYMPIC HOME
FACILITY NUMBER: 419210072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2023
Section Cited
CCR
80072(a)(2)

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80072 Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to conduct in-service training with all staff to ensure hourly or 2-hour checks are provided throughout the night.
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Based on record review and the interviews conducted, the facility was unable to provide documentation to indicate that R1 was checked on and/or changed throughout the night of 11/7/2022. Nevertheless, the facility failed to meet the needs of an incontinent resident
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
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