Olivia's Care Home Iv

On 08/18/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced Post Licensing inspection visit. LPA met with administrator Patricia De Guzman and explained the purpose of today's inspection. There are currently 11 residents in the facility and 4 staff persons working on this day. 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 5 residents and a waiver for 4 bedridden. There are 4 hospice residents at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. The facility itself is the lower level of the home. There is locked access to the facility from the upper floor. The upper floor is privately owned by the landlord of the entire physical plant. The facility garage is on the lower level. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove/range. Medications are locked in a cabinet located in the dining room area. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator for resident food supplies located in the garage along with incontinence supplies and PPE. First aid kit is observed as complete with required items and stored in the medicine cabinet. LPA observed that there are three fire extinguishers in place inspected on 01/07/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull station is located at the front door of the facility. Facility is fully equipped with fire sprinklers. Laundry area is also observed as fully operational, and locked in the garage area of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 05/10/2025. Water temperature is measured at 105F in the common bathroom located at the end of the hall. Cleaning supplies are observed to be locked an not accessible to residents A fire panel is present at the end of the hall with an inspection date of 07/05/2023. Linens are observed as in place in a hallway closet. 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 resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. All resident rooms contain a half bathroom. There are two staff rooms as well which are labeled. 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 5 resident files which are current and 5 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 11/27/2025. The following updated forms are requested to be submitted to CCLD by 08/25/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule No citations issued on this day. Report is reviewed with administrator Patricia De Guzman.

On 08/18/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Patricia De Guzman and explained the purpose of today's inspection. There are currently 11 residents in the facility and 4 staff persons working on this day. 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 5 residents and a waiver for 4 bedridden. There are 4 hospice residents at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. The facility itself is the lower level of the home. There is locked access to the facility from the upper floor. The upper floor is privately owned by the landlord of the entire physical plant. The facility garage is on the lower level. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove/range. Medications are locked in a cabinet located in the dining room area. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator for resident food supplies located in the garage along with incontinence supplies and PPE. First aid kit is observed as complete with required items and stored in the medicine cabinet. LPA observed that there are three fire extinguishers in place inspected on 01/07/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull station is located at the front door of the facility. Facility is fully equipped with fire sprinklers. Laundry area is also observed as fully operational, and locked in the garage area of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 05/10/2025. Water temperature is measured at 105F in the common bathroom located at the end of the hall. Cleaning supplies are observed to be locked an not accessible to residents A fire panel is present at the end of the hall with an inspection date of 07/05/2023. Linens are observed as in place in a hallway closet. 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 resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. All resident rooms contain a half bathroom. There are two staff rooms as well which are labeled. 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 5 resident files which are current and 5 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 11/27/2025. The following updated forms are requested to be submitted to CCLD by 08/25/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule No citations issued on this day. Report is reviewed with administrator Patricia De Guzman.

LPA Jeung met with administrator to review RCFE Component III Orientation. The following topics were discussed: - Operating Requirements - Physical Environment - Personnel Requirements - Resident Records - Reporting Requirements - Health Related Services and Conditions - Dementia Care Pre licensing inspection was conducted on 7/11/24 and licensee has addressed issues identified during that inspection to comply with Title 22 regulations. Facility meets physical plant requirements for licensure of 12 bed Residential Care Facility for the Elderly. Immediate licensure is recommended, pending final approval by Central Applications Bureau.

Applicant Premier Home LLC has applied for RCFE licensure for 12 non-ambulatory elderly clients in 10 rooms. Fire clearance has been approved. Facility is currently licensed and operating under the name Maria's Home for the Elderly #415601025. There are 2 residents who currently receive hospice care. On 5/9/24, LPA Jeung toured facility and grounds of this one level facility. There are 10 bedrooms--each with private half bathrooms--2 staff rooms--1 with half bathroom--full bathroom with 2 shower enclosures, living room/dining room, and kitchen. There are 3 beds in 1 staff room and one bed in the small staff room. Clothes washer and dryer are located on lower level, where there is an additional storage room and 1-car garage. Three other garages are not accessible, and belong to property owner. There is a wood ramp on the south, west (south) and part of north sides of the building, as well as small backyard. Above the facility, there is a separate living unit with a separate entrance, that is not part of RCFE. Medications and toxins are secured in locked cabinets in dining room armoire and stairwell next to kitchen, respectively. Hot water temperature is tested at 103 degrees in common bathroom. Food preparation and service items are present, as well as perishable fruits, vegetables and protein. Supplies of bed and bath linens and hygiene products are observed. First aid kit is complete. Patricia De Guzman is a certified RCFE administrator (x 11/25). LPA Jeung reviewed corrections of deficiencies observed during initial pre-licensing tour on 5/9/24 and citations issued to existing facility, Maria's Home for the Elderly #415601025. Due to unreported CoVID, initial pre-licensing visit was suspended. - Continued on following 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 The following items are observed and must be addressed prior to licensure: 1. A set of keys--including all resident units, facility vehicles, all exit doors, all cabinets, cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies--must be available to staff on each shift for use during an evacuation. (1569.695) 2. Emergency Disaster Plan (LIC610E) must be updated to include corrected utility shut off and fire extinguisher locations. (Section 87212 Emergency Disaster Plan) 3. There is an insufficient 7-day supply of canned fruit (Section 87555 General Food Service). LPA to be contacted upon completion of the above 3 items. Facility phone number is 650/458-3265.

LPA Jeung met with staff and toured facility, including at least 2 private rooms where COVID residents reside. There are no signs posted on doors, no PPE station outside of rooms, only ONE N95 mask available for staff, and LPA was not informed of COVID until AFTER entire facility was toured. This visit is suspended and report will be forwarded to applicant. Facility is not ready for licensure.