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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002771
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:23:03 PM

Document Has Been Signed on 02/09/2022 01:23 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:OLIVE CITY CARE HOMEFACILITY NUMBER:
525002771
ADMINISTRATOR:MENDROS, MARITESFACILITY TYPE:
740
ADDRESS:423 WALNUT STREETTELEPHONE:
(530) 824-2845
CITY:CORNINGSTATE: CAZIP CODE:
96021
CAPACITY: 6CENSUS: 5DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marites MendrosTIME COMPLETED:
01:45 PM
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On 2/9/2022 at 11 AM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a Required - 1 Year Inspection utilizing the infection control domain, LPA met with licensee/administrator Marites Menros and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA Avila and Marites toured the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Avila and the licensee completed the infection control domain and facility was found to be in need of technical assistance.

LPA requested the following documents due by 2/11/2022

Register of Residents
Number of non-ambulatory/bedridden person in care
Personnel Report LIC 500
Emergency and Disaster Plan for RCFE (LIC 610E)
LIC 808
Copy of Administrator Certificate
LIC 9242


No deficiencies are being cited as a result of todays inspection. Technical assistance was provided.

Exit interview conducted and copy of report was provided.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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