Olivia's Care Home Ii

On 07/09/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with administrator/licensee Olivia De Guzman and explained the purpose of today's visit. There are 6 residents present and 2 staff. Annual fees are current. This is a single level facility approved for 2 hospice residents and all may be non-amblatory. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the refrigerator. Medications are observed to be locked in a cabinet adjacent to the refrigerator. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place inspected 05/12/2025, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. The facility has fire sprinkler systems through out. PPE and additional food supplies are observed as in place. Laundry area is also observed in the garage as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 04/17/2025. 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 rooms at random. All rooms observed are free of odors, and contained all the required furniture per regulatory recommendations. All resident rooms are equipped with half baths. There is a full bathroom with walk in shower area for resident use. Water temperature is tested at 107F in this shower room/full bathroom. Shower floor uses non-skid mat when shower is in use. Resident linen supplies are observed as in place in a hallway closet. Cleaning supplies are also observed as locked in a hallway closet and below kitchen sink. There is a staff room, room #1 where there is an attic that is accessed by pull down ladder. Per licensee and observations were made. There are no beds, or staff residing in the attic space. LPA reviewed 6 resident and 3 sstaff files on this day. Per staff files reviewed all files were current with training and CPR/First Aid. Resident files are current as well. Client medications are inspected and are current/logged in centrally stored medication record. Administrator certificate is observed as current expiring on 06/26/2026. The following updated forms are requested to be submitted to CCLD by 07/16/2025 : • Copy of updated Administrator Certificate • LIC500 Staff Schedule No citation issued on this day. Report is reviewed with Oliva and a copy is provided.

In order to amend Facility Evaluation Report of 7/25/22, LPA Jeung issued corrected deficiency page--LIC809D. Corrected copy is signed and given to administrator.

LPA Jeung met with staff and spoke with administrator by phone regarding deficiencies and civil penalties issued on 7/25/22 during annual inspection, for which corrections have not yet been submitted. Per the Facility Evaluation Report issued on 7/25/22, "daily civil penalty of $100/day will accrue until plan of correction is submitted to CCLD and approved by LPA." Administrator Olivia De Guzman overlooked su bmitting proof of correction to LPA. However, LPA observed that daily temperature and COVID symptom checks are logged for staff and residents, starting 7/26/22. See acknowledgement of correction and additional civil penalty assessment--$100 for 7/26/22.

LPA Jeung inspected attic in response to citation issued on 7/30/21 during annual inspection, and plan of correction submitted on 8/2/21 by administrator that attic rooms have been vacated and will not be used for occupancy. All personal items--including clothing and electronics--and furnishings have been removed from 3 rooms. Mattresses and box springs are stripped and leaning against walls. It is noted that staff room on ground level where attic ladder is accessed has been modified, in that a wall has been removed. It is now consistent with the facility sketch submitted in 2019 upon licensure. Acknowledgement of correction is issued today--1 page.