525002771-2-11-2021-25-AS-JAVA-BY5TVM-20210211140411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525002771
Report Date: 02/11/2021
Date Signed: 02/11/2021 02:06:18 PM

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 HOME		FACILITY NUMBER:	525002771
ADMINISTRATOR:	MENDROS, MARITES		FACILITY TYPE:	740
ADDRESS:	423 WALNUT STREET		TELEPHONE:	(530) 824-2845
CITY:	CORNING	STATE: CA	ZIP CODE:	96021
CAPACITY:	6	CENSUS: 0	DATE:	02/11/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Marites Mendros, Administrator		TIME COMPLETED:	01:15 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) Jaclyn Avila conducted a Pre-Licensing inspection of the facility via FaceTime with Administrator Marites Mendros. The facility consists of a single-story home. The home consists of 1 kitchen, 3 bathroom(s), 3 half bathroom(s), 1 dining room, 1 living room, 1 laundry room, and 10 bedrooms. The facility has requested licensure for a capacity of 6 residents (0 ambulatory, 6 non-ambulatory, 2 hospice). Currently there are 0 residents in care at the facility. LPA Avila toured the facility with the administrator Marites Mendros. The physical plant is consistent with the submitted facility sketch/floor plan. The facility is clean and in good repair. The facility temperature is between 68 degrees and 78 degrees. All window screens are clean and in good repair. There is appropriate lighting in the facility and in each room. There is a locked centralized storage area for resident medications. Protective devices are in use such as non-slip material on rugs. Indoor and outdoor passageways and stairways are free of obstruction. Stairways, inclines, ramps, open porches, and areas of potential hazard accessible to residents are well-lit and equipped with sturdy hand railings. Disinfectants, cleaning solutions, poisons, and other items which could pose a danger are inaccessible. Fire alarms and smoke alarms operate properly. Carbon monoxide detectors operate properly. LPA did discuss having an additional Carbon monoxide detector on the side of the house with the bedrooms. LPA discussed this with licensee due to a wood burning fireplace in the home that is in use. The fireplace is protected by an iron gate. Resident bedrooms are large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture, and any resident assistant devices such as wheelchairs or walkers. There is a bed for each resident equipped with good springs, clean and comfortable mattress, pillow(s), and bedding. Mattresses and pillows are flame retardant. There is a chair, night stand, chest of drawers, and lamp or sufficient lighting for each resident. There is at least eight (8) cubic feet of drawer space for each resident.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OLIVE CITY CARE HOME	FACILITY NUMBER: 525002771
	VISIT DATE: 02/11/2021

NARRATIVE

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Bathroom floors are clean and sanitary. All bathtubs, showers, and toilets have grab bars. All bathtubs and showers have non-skid mats or strips. All bathtubs, showers, toilets, and sinks operate properly. There is a sufficient supply of hygiene items such as soap and toilet paper. There is a sufficient supply of clean linen, including blankets, bedspreads, top sheets, bottom sheets, pillowcases, bath towels, hand towels, and wash cloths, to permit changing weekly or more often as needed.

Kitchen and dining room floors are clean, sanitary, and odorless. Trash cans have tight fitting covers. Kitchen areas are clean and free of litter, rodents, vermin and insects. There are no pesticides, poisons, or other toxic substances stored in any food storage or preparation area or with utensils. Cleaning supplies are kept in areas separate from food supplies. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food.
There is confidential storage of personnel records at the facility. There is confidential storage of resident records at the facility.

Facility Theft and Loss Program is posted. The Licensing Complaint Poster is posted. Resident Personal Rights are posted. Posting Title 22, Section 87468 and Health and Safety Code, Section 1569.269 meets this requirement. Resident Council Rights are posted. Posting a copy of the Rights of Resident Councils PUB 747 meets this requirement.

There are activity supplies and equipment, including access to daily newspapers, current magazines, and a variety of reading materials. There is an outdoor activity area equipped for outdoor use. There is a comfortable and appropriately furnished area such as a living room for residents to entertain friends and relatives.

There is a first aid kit, including sterile dressings, bandages, thermometer, scissors, tweezers, and a current first aid manual. There are laundry supplies and equipment, including at least one machine in good repair. There is a space for clean linen storage and a separate space for soiled linen.

There is an operating telephone available to residents. Emergency lighting supplies e.g., flashlights, batteries are present. Vehicles used to transport residents are in safe operating condition.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OLIVE CITY CARE HOME	FACILITY NUMBER: 525002771
	VISIT DATE: 02/11/2021

NARRATIVE

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DEMENTIA CARE
Knives, matches, tools and other items that could constitute a danger were not inaccessible. LPA discussed the need to lock items up and what type of items constitute a danger. Licensee will implement additional safety measure to ensure these items are not accessable. Over the counter medications, nutritional supplements or vitamins, alcohol, and cigarettes are inaccessible. Toxic substances such as certain plants, gardening supplies, cleaning supplies, and disinfectants are inaccessible. Outdoor activity space is completely enclosed by a fence with self-closing latches and gates, or walls. Auditory devices are in place to monitor exits, if exiting presents a hazard to any resident.

LPAs observations of deficiency are as following:

Kitchen at 9:25 AM temp is 122 degrees Fahrenheit

The hot water temperature is not between 105-120 degrees Fahrenheit. Administrator will adjust and monitor daily for a week.

Comp III completed. LPA provided Licensee with COVID-19 materials as well as link to the Provider Information Notifications (PINS).

No deficiencies were cited at today’s tele-visit. Pre-Licensing is incomplete with deficiencies to be resolved by Feb 18^th, 2021

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC809 (FAS) - (06/04)

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