Olivia's Care Home

On 07/29/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with designated responsible staff person Patricia De Guzman and explained the purpose of today's inspection. There are currently six residents in the facility. There are 3 staff present, one being the co-administrator, and 6 residents. This is a single level facility, licensed for residents age range of 60 years and over all of which may be non-ambulatory with a hospice waiver for three residents. There are no hospice residents at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. To the rear of the facility is a garage that is not part of the facility and the licensee/administrator does not have access to. There is a two level private dwelling located at the rear of the facility that does not have access into the facility. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen cabinet adjacent to the sink. Medications are also locked in a cabinet adjacent to the sink. Perishable and non-perishable food items are observed as in place. There are two additional refrigerators and freezer for resident food supplies located in a staff room. First aid kits are observed as complete with required items and stored at time of visit at the end of the hallway on a table with PPE. LPA observed that there are two fire extinguishers in place inspected on 05/22/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull stations are located at the front door and rear side door of the facility. Facility is not equipped with fire sprinklers. Laundry area is also observed as fully operational, and lockable, at the end of the hallway. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 02/03/2025 per file reviewed but according to Olivia via telephone call, a drill was conducted in April 2025 but the record is not on file. Water temperature is measured at 112F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the laundry area at the end of the hall. A fire panel is present and located in the same close as the linens. An inspection tag is on the panel. Continued on next page... 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 26 27 28 29 30 31 32 Page 2 LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. There are two staff rooms at the rear of the facility marked as "Private". Resident linen supplies are observed as in place stored in a hallway closet. There is one common full bathroom located in the hallway. Shower floor does have non-skid mats present for use. During today's inspection LPA reviewed six resident files which are current and three staff files which are current. Training hours are on file as current for staff. Medications are inspected and are accurate to what is listed on centrally stored medication and destruction record. Administrator certificate is current expiring on 08/26/2026. The following updated forms are requested to be submitted to CCLD by 08/05/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued on this day. Report is reviewed with designated responsible staff person Patricia De Guzman and a copy is provided. Technical violations are issued on the following LIC9102TV pages.

On 08/23/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Olivia De Guzman and explained the purpose of today's inspection. There are currently five residents in the facility, one is currently in the hospital. No residents are on hospice at this time. One resident uses oxygen. This is a single level facility, licensed for residents age range of 60 years and over all of which may be non-ambulatory with a hospice waiver for three residents. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. To the rear of the facility is a garage that is not part of the facility and the licensee/administrator does not have access to. There is a two level private dwelling located at the rear of the facility that does not have access into the facility. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen cabinet adjacent to the sink. Medications are also locked in a cabinet adjacent to the sink. Perishable and non-perishable food items are observed as in place. There are two additional refrigerators and freezer for resident food supplies located in a staff room. First aid kits are observed as complete with required items and stored at time of visit at the end of the hallway on a table with PPE. LPA observed that there are two fire extinguishers in place inspected on 05/23/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull stations are located at the front door and rear side door of the facility. Facility is not equipped with fire sprinklers. Laundry area is also observed as fully operational, and lockable, at the end of the hallway. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 07/13/2024. Water temperature is measured at 107F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the laundry area at the end of the hall. A fire panel is present and located in the same close as the linens. An inspection tag is on the panel but LPA cannot determine the date of last inspection. Continued on next page... 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 26 27 28 29 30 31 32 Page 2 LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. There are two staff rooms at the rear of the facility marked as "Private". Resident linen supplies are observed as in place stored in a hallway closet. There is one common full bathroom located in the hallway. Shower floor is equipped with non-skid mat. During today's inspection LPA reviewed four resident files which are current and three staff files which are current. Training hours are on file as current for staff. Medications are inspected and are accurate to what is listed on centrally stored medication and destruction record. The following updated forms are requested to be submitted to CCLD by 08/30/2024 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued on this day. Report is reviewed with Olivia De Guzman and a copy is provided.

LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms--each with private half bathrooms--and 2 staff bedrooms; rear staff room has one bed and the other has a bunk bed for 2 staff. There is a room that is not accessible in the rear of building--on left side--that administrator advised is occupied by an independent renter who has criminal record clearance. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff, plus the administrator. Two residents are receiving hospice services. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Olivia De Guzman is a certified RCFE administrator (x 6/22) that oversees facility operations. Copies of training certificates for 40 hours is observed, as well as check register which shows payment to CDSS for renewal of administrator certificate. Proof of current Liability Insurance is requested to be sent to CCLD by 8/19/22. Updated Personnel Report (LIC500) is given to LPA today. No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. Facility is operating in substantial compliance.