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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002771
Report Date: 04/28/2023
Date Signed: 04/28/2023 11:37:23 AM

Document Has Been Signed on 04/28/2023 11:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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: 8CENSUS: 6DATE:
04/28/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Marites and Erico MendrosTIME COMPLETED:
11:45 AM
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LPA Hiratsuka, conducted this case management visit as a follow-up to an increase in capacity and room change request. LPA toured the facility to ensure all the rooms are ready for residents.

The facility requested an increase in capacity and a room change earlier this month. The fire clearance was granted by the fire department. The facility now has a non-ambulatory fire clearance for eight residents. LPA also reminded Licensee that the annual fees have increased due to the increase in capacity.

Per the fire clearance, rooms one, three, four, six, eight, and nine are private resident rooms. Room seven is cleared to be a shared room. This is a total capacity of eight. What used to be resident room five is now going to be used as an office and storage per the Licensees. Bedroom number two is the staff room and is in the same hallway as resident rooms one and three.

There is a room off the kitchen that is used for storage, laundry, and overnight use for the licensee.

A couple of topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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