075601238-5-10-2024-15-AS-LAWN-D55UMW-20240510154302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601238
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:43:14 PM

Document Has Been Signed on 05/10/2024 03:43 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:	05/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Conchita Gozun, Licensee/Administrator		TIME COMPLETED:	04:00 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 05/10/2024 at 11:30 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Direct Support Caregiver, Catalina Atienza, and explained the purpose of the visit. Catalina phoned, Administrator, Conchita Gozun, to inform. Conchita arrived approx. 1 hour later. The facility’s fire clearance was approved for capacity six (6) in which five (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 75 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 105 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 08/15/2023. Emergency Disaster Plan was last posted on 05/10/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 04/19/2024 and 04/28/2024. LIC809-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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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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Document Has Been Signed on 05/10/2024 03:43 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. 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 by having updated Appraisal Needs and Services (ANS) for R1-R5 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2024
	Plan of Correction
1 2 3 4	Administrator agreed to update ANS and submit to CCLD by POC due date.

Type B

Section Cited

CCR

87458(c)

87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. 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 By having updated Physician's Reports for R1, R3 and R4 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2024
	Plan of Correction
1 2 3 4	Administrator agreed to send updated Physician's Reports 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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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: 05/10/2024

NARRATIVE

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LIC809-C Continued...

LPA reviewed 5 residents records. LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/17/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance
Copy of Facility Sketch
Current Administrator’s Certificate - Reviewed

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.

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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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