075601238-6-8-2023-15-AS-LAWN-CSM3NV-20230608182434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601238
Report Date: 06/08/2023
Date Signed: 06/08/2023 06:24:43 PM

Document Has Been Signed on 06/08/2023 06:24 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 RESIDENTIAL CARE HOME		FACILITY NUMBER:	075601238
ADMINISTRATOR:	GOZUN, CONCHITA Q.		FACILITY TYPE:	740
ADDRESS:	2252 OLYMPIC DRIVE		TELEPHONE:	(925) 370-7338
CITY:	MARTINEZ	STATE: CA	ZIP CODE:	94553
CAPACITY:	6	CENSUS: 5	DATE:	06/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:43 PM
MET WITH:	Catalina Atienza, Caregiver		TIME COMPLETED:	06:45 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 06/08/2023 at 3:43 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Catalina Atienza and explained the purpose of the visit. LPA spoke with the Licensee/Administrator Conchita Gozun who was out at a doctor's appointment with one of the resident. The facility’s fire clearance was approved for 6 where 5 may be non-ambulatory. LPA toured facility with Catalina including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 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 74 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 109.5 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 08/15/2022. Emergency Disaster Plan was last posted 07/02/2021. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 05/18/2023. LPA reviewed 1 residents records. LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. LIC 809-C Continued...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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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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 RESIDENTIAL CARE HOME	FACILITY NUMBER: 075601238
	VISIT DATE: 06/08/2023

NARRATIVE

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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 3:50 PM LPA observed scissors unlocked and keys hanging in the kitchen
At 3:55 PM LPA observed 2 wheelchairs, floor lamp, portable toilet camode, wood table set with 4 chairs, bike, ice chest cooler, bag of plastic bottles, 45 watt solar panel kit box, cardboard boxes and a radio boom box located outside back yard

At 4:15 PM LPA observed during resident record review that there was only 1 resident file available for review.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 06/15/2023:

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

Exit interview conducted. Appeal Rights and a copy of this report provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/08/2023 06:24 PM - It Cannot Be Edited

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 RESIDENTIAL CARE HOME	FACILITY NUMBER: 075601238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a pair of scissors accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Caregiver immediately removed pair of scissors that were on the desk and placed in locked caregiver bedroom which makes the pair of scissors inaccessible. Deficiency cleared during visit.

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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/08/2023 06:24 PM - It Cannot Be Edited

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 RESIDENTIAL CARE HOME	FACILITY NUMBER: 075601238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (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
1 2 3 4	Based on observation the licensee did not comply with the section cited above in having 2 wheelchairs, floor lamp, toilet camode, solar panel kit, cardboard boxes, radio boom box accessible which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will remove items and clean the outside backyard. Submit photos to CCLD by POC due date.

Type B

Section Cited

CCR

87506(a)

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 having all resident's records available at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will maintain all resident's records at the facility. Submit photos that all of the resident's records are located, stored and available at the facility to CCLD by POC due date.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

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