Olivia's Care Home III

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Mar 13, 2026

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Feb 27, 2025

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Apr 8, 2024