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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600237
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:08:27 PM


Document Has Been Signed on 02/02/2024 03:08 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:OLYMPIC RETIREMENT HOMEFACILITY NUMBER:
075600237
ADMINISTRATOR:LIMPIN, ELENAFACILITY TYPE:
740
ADDRESS:1862 OLYMPIC DRIVETELEPHONE:
(925) 372-8624
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 1DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Elena Limpin, Licensee/AdministratorTIME COMPLETED:
03:25 PM
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On 02/02/2024 at 12:15PM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee/Administrator, Elena Limpin and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6), in which four (4) may be non-ambulatory. Hospice waiver for three (3) residents. Administrator certificate #6024147740 expires 02/20/2025.

LPA toured facility with Elena including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 117.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/28/2023. Emergency Disaster Plan did not have a date. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/02/2022.

LPA reviewed 1 resident records. LPA reviewed 2 staff records and 0 of 2 have current first aid training and associated to the facility.

LIC809 Continued..
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OLYMPIC RETIREMENT HOME
FACILITY NUMBER: 075600237
VISIT DATE: 02/02/2024
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LIC809-C Continued...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/09/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (all 9 pages)
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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