Olivia's Care Home Iii

On 02/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with the administrator Olivia De Guzman today and explained the purpose of today's visit. Currently there are 2 staff and the administrator present assisting the 6 residents. There are 4 residents eating when LPA arrived to the facility. This is a two level facility but the upstairs of the facility is a private rental. There is also another private rental in the backyard of the facility in a disconnected smaller home. Facility is licensed for age range 60 and over all of which must be ambulatory. Facility is cleared for 3 hospice residents. 3 residents are on hospice as of today's visit. The facility operates on the ground floor of this address only. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Laundry area is in the garage and is fully functional. Knives are locked in the kitchen drawer adjacent to the stove/range. Medications are locked in the island area of the kitchen. Toxic chemicals and cleaning supplies are observed in the hallway closet. PPE are in place as stored in the dining room area in a cabinet and garage. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. LPA observed a fire extinguisher in the kitchen and at the end of the hallway as fully charged ready for use. 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 Facility has one common full bathroom for resident use. All resident rooms are also equipped with half bathrooms as well. Shower floor is equipped with non-skid flooring. Water is tested at 105F in the common bathroom and in the kitchen it was tested at 108F. Based on review of all resident files, and medications all items are current and logged accurately. Staff files are reviewed and are current. Emergency disaster drill records are observed as current being conducted quarterly. Last drill was conducted on 01/32/2026. Administrator certificate is observed as current expiring 11/27/2025. Renewal items were sent to Administrator Certification Bureau and indicated that it is pending and renewal status is ongoing. The following updated forms are being requested to be received by 03/20/2026: • Copy of Administrator Certificates • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC500 Staff Schedule There are no citations issued during today's inspection visit. Report is reviewed with Olivia De Guzman and a copy is provided.

On 02/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with staff person Neil Magdaraog today and explained the purpose of today's visit. Currently there are 2 staff present and 5 residents. All residents are in their rooms by choice. Around 11:16pm the administrator Patricia De Guzman arrived and met with LPA. This is a two level facility but the upstairs of the facility is a private rental. There is also another private rental in the backyard of the facility in a disconnected smaller home. Facility is licensed for age range 60 and over all of which must be ambulatory. Facility is cleared for 3 hospice residents. 1 resident is on hospice as of today's visit. The facility operates on the ground floor of this address. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Laundry area is in the garage and is fully functional. Knives are locked in the kitchen drawer adjacent to the stove/range. Medications are locked in the island area of the kitchen. Toxic chemicals and cleaning supplies are observed in the hallway closet. PPE are in place as stored in the dining room area in a cabinet and garage. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. LPA observed a fire extinguisher in the kitchen with an inspection tag of 05/23/2024 which is charged and ready for use. 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 Facility has one common full bathroom for resident use. All resident rooms are also equipped with half bathrooms as well. Shower floor is equipped with non-skid flooring. Based on review of all resident files, and medications all items are current and logged accurately. Staff files are reviewed and are current. Emergency disaster drill records are observed as current being conducted quarterly. Last drill was conducted on 01/30/2025. Administrator certificate is observed as current expiring 11/27/2025 per online review. A physical certificate was never received by the administrator. The following updated forms are being requested to be received by 03/06/2025: • 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 There are no citations issued during today's inspection visit. Technical violations are issued on the attached two pages. Report is reviewed with Patricia De Guzman and a copy is provided.

LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms and staff room--all with half bathrooms--on ground level, as well as living/dining room. There is a staff room on lower level adjacent to garage, and a 2-bedroom rental unit on 2nd floor; this apartment is accessed through garage. In addition, there is an accessory dwelling unit in backyard, that has a separate address. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete and maintained. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. An updated Disaster and Mass Casualty Plan is available. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Olivia De Guzman (x 6/24) is a certified RCFE administrator that oversees facility operations. Staff records, including training, will be reviewed at a later date. As per legislation, effective 1/1/2015, the following information is posted: 1) PUB474, pertaining to resident councils, per AB1572; 2) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 3) CCLD Hotline information, per SB895. Administrator is requested to submit the following updated information/forms to CCLD by 4/22/24: - Administrative Organization (LIC309) - Personnel Report (LIC500) No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. See Advisory Notes issued--5 pages.

On October 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced collateral investigation visit to deliver findings to a complaint received under previous licensee. LPA met with Caregiver, Annalissa Condez and explained the purpose of the visit. LPA explained that the visit was in relation to complaint being received under the previous licensed facility, Rosie's Home For The Aged who used to be licensed at this facility's current address. Report is reviewed with Caregiver, Annalissa Condez and a copy is provided.

On October 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Caregiver, Annalissa Condez, and explained the purpose of the visit. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA was screened at entry point and Caregiver was able to provide LPA with screening log documentation for residents, staff, and visitors. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a double story home, however the second story is being rented out. The first story is observed to have 7 bedrooms, 6 of which are private resident rooms and 1 is utilized as a staff room. Each bedroom has their own half-bathroom. There is one shared bathroom observed. LPA observed hand-washing signs in all bathrooms. LPA Charitra advised caregiver to ensure that there are no bar soaps or hand-towels present in the shared bathroom and ensure that there are paper-towels and liquid soap present instead. In addition, LPA advised caregiver to ensure all trash-cans have a fitted lid. LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. COVID-19 signage was posted throughout the facility. Extra linen was observed to be present. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps and medications were observed to be locked and inaccessible to residents. LPA advised caregiver to remove hand towels. Kitchen was observed to be equipped with liquid soap and paper-towels, with hand-washing signs. LPA toured the garage and observed chemicals and toxins to be locked. In addition, LPA observed washer and dryer to be in good condition and observed extra food supply present. 30-day PPE supply was present. There is a staff room in the garage. According to the Caregiver, the garage stays locked at all times and it is inaccessible to residents. Staff first aid cards were observed to be current. Infection control practices are observed: COVID signage posted throughout the facility, entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies. No citations will be issued during this visit. Report is reviewed with Caregiver, Annalissa Condez and a copy is provided. LPA requests the following to be submitted to CCLD by 10/12/2022: -LIC308 Designation of Administrative Organization -LIC500 Personnel Report -LIC610E Emergency Disaster Plan -Administrator Certificate

On this day Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced collateral investigation visit in conjunction to a complaint received under previous licensee. LPAs met with Annalissa Condez and explained the purpose of today's visit. LPAs explained that the visit was triggered due to a complaint being received under the previous licensed facility Rosie's Home For The Aged who used to run at this facility's current address. These allegation and investigation does not pertain to the current licensee at this time. Report is reviewed with Annalissa. No citations issued.