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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002771
Report Date: 02/18/2025
Date Signed: 02/18/2025 03:11:10 PM

Document Has Been Signed on 02/18/2025 03:11 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OLIVE CITY CARE HOMEFACILITY NUMBER:
525002771
ADMINISTRATOR/
DIRECTOR:		MENDROS, MARITESFACILITY TYPE:
740
ADDRESS:423 WALNUT STREETTELEPHONE:
(530) 824-2845
CITY:CORNINGSTATE: CAZIP CODE:
96021
CAPACITY: 8CENSUS: 8DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Marites Mendros - administratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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02/18/2025 12:30 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Marites Mendros Administrator(7020141740 exp.09/18/2025) and explained the purpose of the visit.

LPA and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to eight (8) resident rooms, common areas, six (6) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked office.



The common area, kitchen, and bathrooms were clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. All bedrooms had required furniture, bedding, and lighting.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. All employees requiring background checks are cleared.

There are no pools/bodies of water are on the premises. The last emergency evacuation drill was conducted in October 2024 which was a fire drill.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OLIVE CITY CARE HOME
FACILITY NUMBER: 525002771
VISIT DATE: 02/18/2025
NARRATIVE
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LPA requested administrator submit the following documents to the Chico office:

Copy of current administrator certificate, LIC402 surety bond, current liability insurance, LIC500 Personnel report.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



LPA observed Clorox wipes and spray air freshener accessible to residents in one bathroom. LPA observed multi-purpose spray cleaner in kitchen accessible to residents.

LPA observed warn paint and wood areas in the decking and ramps located on the north, south, and east sides of the facility. LPA observed a section of fence missing from the west side of the facility. LPA observed the following discarded items that need to be removed from the premises: dryer, hoyer lift.

LPA observed that two of four staff files were missing current first aid training certificates.

LPA observed that 1 of 4 resident files is missing a physicians report and TB clearance.

Exit interview conducted and copy of report and appeal rights were provided to administrator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2025 03:11 PM - It Cannot Be Edited


Created By: Rebecca Knight On 02/18/2025 at 02:28 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OLIVE CITY CARE HOME
FACILITY NUMBER: 525002771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) 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
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Based on LPA observation warn paint and wood areas in the decking and ramps located on the north, south, and east sides of the facility. LPA observed a section of fence missing from the west side of the facility. LPA observed the following discarded items that need to be removed from the premises: dryer, hoyer lift. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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Licensee shall submit a plan to LPA as to when the repair of the decking can be completed and will submit photographs to LPA when the repairs have been completed as proof of correction. Licensee shall removed the discarded items immediately and send photographs to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2025 03:11 PM - It Cannot Be Edited


Created By: Rebecca Knight On 02/18/2025 at 02:36 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OLIVE CITY CARE HOME
FACILITY NUMBER: 525002771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
87309 Storage Space and Access



(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation Clorox wipes and spray air freshener accessible to residents in one bathroom. LPA observed multi-purpose spray cleaner in kitchen accessible to residents. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee agrees to conduct staff training on the requirement to store all cleaning supplies inaccesible to residents in care. Licensee shall submit stagg sign in sheet to LPA as proof of correction.
Type B
Section Cited
CCR
87458

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation 1 of 4 resident files is missing a physicians report and TB clearance.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2025
Plan of Correction
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Licensee shall submit physicians report with TB clearance for 1 resident to LPA as proof of correction.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


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Document Has Been Signed on 02/18/2025 03:11 PM - It Cannot Be Edited


Created By: Rebecca Knight On 02/18/2025 at 02:44 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OLIVE CITY CARE HOME
FACILITY NUMBER: 525002771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation two of four staff files were missing current first aid training certificates.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee agrees to submit current first aid certificates for two staff to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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