525002771-3-17-2026-59-AS-KADN-DS9RQJ-20260317131339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525002771
Report Date: 03/17/2026
Date Signed: 03/17/2026 01:16:00 PM

Document Has Been Signed on 03/17/2026 01:16 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 HOME		FACILITY NUMBER:	525002771
ADMINISTRATOR/ DIRECTOR:	MENDROS, MARITES		FACILITY TYPE:	740
ADDRESS:	423 WALNUT STREET		TELEPHONE:	(530) 824-2845
CITY:	CORNING	STATE: CA	ZIP CODE:	96021
CAPACITY: 8		CENSUS: 7	DATE:	03/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Marites Mendros, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	On March 17, 2026, Licensing Program Analyst (LPA) Kayla Adkison, arrived at the facility unannounced to conduct a Required Annual Inspection. LPA met with Marites Mendros, Administrator, and explained the purpose of the visit. During the inspection, there were 7 residents and 2 staff providing direct care. LPA observed residents eating, watching television, and participating in bible study/music. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, eight (8) resident bedrooms, three (3) bathrooms, kitchen, storage areas, and backyard. All areas observed were found to be clean and in good repair. All walkways were clear of obstructions. LPA observed each bedroom to have the required furnishings and working lights. Each resident bedroom has an exterior door to the backyard which are alarmed. LPA observed the facility to be at a comfortable temperature. There were various activities available for client recreation including games, cards, movies, and books. Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed all medications, sharps, and cleaning supplies to be locked away and inaccessible to clients in care. LPA reviewed Medication Administration Records (MARs) and found them to be current and accurate. LPA observed (2) two fire extinguishers which were last inspected in January 2026. Smoke detectors and carbon monoxide detectors were observed and found to be in working condition. The facility is conducting emergency disaster drills with the last drill being documented in January 2026. LPA observed a complete first aid kit ready for use. Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 03/17/2026

NARRATIVE

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In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) resident files and two (2) staff files. One (1) of two (2) staff files did not have record of a medical assessment. Two (2) of two (2) staff files had no record of a negative tuberculosis test. All staff are fingerprint cleared and associated to the facility. Administrator certificate is current.

Deficiencies are being cited from the California Code of Regulations, Title 22, and are recorded on the attached LIC 809-D. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and and Appeal Rights were provided to Administrator, Marites Mendros, via email.

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/17/2026 01:16 PM - It Cannot Be Edited

Created By: Kayla Adkison On 03/17/2026 at 12:01 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: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that two (2) of two (2) staff files had no record of a negative tuberculosis test which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2026
	Plan of Correction
1 2 3 4	Licensee agrees to send LPA proof of negative tuberculosis tests/xrays for two (2) staff via email by end of business on April 17, 2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:

	Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/17/2026 01:16 PM - It Cannot Be Edited

Created By: Kayla Adkison On 03/17/2026 at 12:01 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: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that one (1) out of (2) two staff files did not have a record of a completed health assesment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2026
	Plan of Correction
1 2 3 4	Licensee agrees to submit a completed health assessment for one (1) staff by end of business on April 17, 2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:

	Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC809 (FAS) - (06/04)

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