435200192-1-13-2024-26-AS-MMOR-CZG23K-20240113160227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200192
Report Date: 01/13/2024
Date Signed: 01/13/2024 04:03:00 PM

Document Has Been Signed on 01/13/2024 04:03 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	OLGA'S CARE HOME FOR THE ELDERLY		FACILITY NUMBER:	435200192
ADMINISTRATOR:	ATIENZA-BILAN, OLGA		FACILITY TYPE:	740
ADDRESS:	954 JUNESONG WAY		TELEPHONE:	(408) 272-7040
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS: 5	DATE:	01/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Administrator Olga Atienza-Bilan		TIME COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Olga Atienza-Bilan. During visit, LPA observed 5 residents and 2 staff. LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, restrooms and residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 108 degrees F in resident bathrooms. While touring the kitchen, LPA requested to see the inside of the garage. LPA observed the door to the garage gets jammed and is difficult to close. ADM stated she has called repairman to address the door. While touring the backyard, LPA observed, bedroom #3's sliding door, does not have a screen. ADM stated it was removed because it was broken. (Photographs were taken.) Fire extinguisher was serviced in January 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. ADM stated the last fire drill conducted was on December 2023, but doesn't have a log. Page 1 out of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OLGA'S CARE HOME FOR THE ELDERLY	FACILITY NUMBER: 435200192
	VISIT DATE: 01/13/2024

NARRATIVE

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LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 & ADM) and 3 residents (R1-R3).

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Olga Atienza-Bilan and a copy of the signed report & appeal rights were provided.

Page 2 out of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/13/2024 04:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OLGA'S CARE HOME FOR THE ELDERLY	FACILITY NUMBER: 435200192
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. Based on LPA's observation, the facility garage door, connected directly to the kitchen gets jammed and is difficult to close. LPA also observed bedroom #3's screen door screen is missing. ADM stated the screen was removed because it was broken. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2024
	Plan of Correction
1 2 3 4	ADM stated she will send a plan of action on how the facility will ensure the home is in good repair at all times. ADM stated she will send plan of correction to LPA by POC date, 1/20/2024.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. ADM stated a fire drill was conducted in December 2023, but does not have a log. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2024
	Plan of Correction
1 2 3 4	ADM stated she will create a fire drill log. ADM stated she will send LPA documentation that a fire drill has taken place. ADM stated she will send the plan of correction to LPA by POC date, 1/20/2024.

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: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

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