Olympic Board & Care

Type of visit: Required - 1 Year

License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Administrator Jurate Ezerskiene. The purpose of today’s visit was explained. The facility is licensed to serve 6 non-ambulatory residents over the age of 60, with a hospice waiver for 6. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows: FACILITY PHYSICAL PLANT The facility is located in a residential area and consist of a single home with 4 resident bedrooms, 2 bathrooms, a kitchen, a living room, a dining room, a staff room, and a back yard. The home has a second unit in the back which is not part of the license. There were no body of water observed in the property. REVIEW OF FILES Resident record review consisted of Admission Agreements, Identification and Emergency Info, Physician Reports, Consent Report, Needs and Service Plan, Personal Rights, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. Resident R2, R3, and R4 were missing Physician reports. S4 did not and deficiency is noted on LIC-809D. (Report continues on page LIC-809c) Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents. Wall and floors are in good repair. Hallways were clean and free of obstructions. Exit doors were observed with auditory devices to alert staff for residents with dementia. Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees. Sharps are locked inside the kitchen cabinet and inaccessible to residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents. Carbon monoxide/Smoke detectors were tested and are in working condition. Fire extinguisher was observed in hallway. Required posters were observed in the hallway and dining room. Last fire drill and disaster drill was conducted on 03/05/2025. A deficiency is noted on LIC-809D for not conducting drills every quarter. Front and back yards are free of hazards. Back yard has a shaded seating area for residents to enjoy. The medications are centrally stored and locked in a living room cabinet. LPA reviewed medications for all five (5) residents. The facility did not provide a written prescription order from a physician for residents R1-R5 that identified the list of prescriptions to administer to residents in care. A deficiency is noted on LIC-809D. LPA conducted interviews with two residents and two staff. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview was held and copies of reports LIC-809, LIC-809C, LIC 809D, and Appeal Rights were discussed and provided to Administrator Jurate Ezerskiene.the state’s words, verbatim · CDSS document, Feb 3, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jurate Ezerskiene and explained the reason for the visit. The facility is licensed to served 6 non-ambulatory residents over the age of 60, with a hospice waiver for 6. The facility is located in a residential area and consist of a single home with 4 resident bedrooms, 2 bathrooms, a kitchen, a living room, a dining room, a staff room, and a back yard. The home has a second unit in the back which is not part of the license. LPA conducted a tour of the facility and observed the following: Facility is in good repair. Living and dining rooms were observed clean with sufficient furniture for residents. Activity supplies were observed in the dining room area. Medications were locked in a cabinet in the living room. Kitchen area was observed clean and in good repair and is not accessible to the residents. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. No special diets were noted by residents' physicians. A total of 4 resident bedrooms were observed in good repair, with sufficient lighting and bedding supplies. Bedroom #1-5(BR1-5) were observed with full and half bed rails. Oxygen signs were posted as required. Two bathrooms were observed to be clean and in good repair, with skid strips and grab bars. Water temperature was tested between 114.8-115.5 degrees F. which is within the required temperature. Carbon monoxide/Smoke detectors were tested and are in working condition. Fire extinguisher was observed in hallway. Required posters were observed in the hallway and dining room. Outdoor area was observed with personal items clutter on top of covered seating area, on the right to the building blocking passageway and exit driveway. Exit doors were observed without auditory devices and facility services residents with dementia. (CONTINUED ON LIC 809C) Medications were reviewed for 6 residents. Medications listed on physician's orders were not observed during review for Resident #4-6(R4-R6). Files were reviewed for 6 residents. Resident #5(R5) is not on hospice and does not have a request for full bed rails, full bed rails were observed in bed(BR1). Resident #3(R3) does not have a notification of sharing a bedroom with a resident in hospice and does not have a half bed rail request on file. Resident #2(R2) does not have a full bed rail request on file. Full bed rails were observed in bed. Resident #6(R6) does not have a half bed rail request on file. Resident #4(R4) does not have a full bed rail request on file. LPA reviewed 2 staff files. Per resident recently 2 staff have quit and are in the process of hiring staff. Administrator certificate was observed for JURATE EZERSKIENE #601608740 exp. date: 4/29/24. Per administrator no documentation or education has been completed for renewal. Staff #2 did not have Health screening or TB test on file. First aid training has not been completed for either staff. Emergency disaster and infection control plans were reviewed. Emergency disaster plan version (10/03) was observed which does not meet the requirements of version (12/21). LPA interviewed 2 residents and 2 staff. Deficiencies were noted per Title 22 Regulations. Exit interview was conducted with Jurate Ezerskiene and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2025

The state marks this report as 11 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with House Manager Justina Millan and explained the purpose for the visit. The facility is licensed to serve six (6) non-ambulatory residents, ages 60 years and over. Approved Hospice Waiver for 6. Currently, there are six (6) residents in placement. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs (SHN). During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. There is a visitor sign-in/ screening station located in the main entrance. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per House Manager, six (6) residents have COVID-19 vaccines including boosters. Per House Manager, all staff also have the COVID-19 vaccines including boosters. The facility is adhering to infection control requirements. Refer to LIC 809C for continuation of report Operational Requirements: Fire Drills are conducted quarterly, the last fire drill was conducted on 11/1/23. Emergency Disaster/ Earthquake Drills are also conducted quarterly and the last one was conducted on 11/1/23. Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility consists of: Living room, dining area, kitchen, four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, detached guest home in the backyard (residents do not have access to) and an outside shaded patio. All resident rooms were checked. All resident beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Bathrooms are clean, sanitary and operational with grab bars and non-skid mats in place. Water temperature properly measured at 119F*. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front yard is free of debris and/or hazards. A shaded area with chairs is provided for residents in the rear porch of the facility Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator is current and the expiration date is 04/29/24. Refer to LIC 809C for continuation of report Resident Records-Incident Reports: LPA reviewed Client files for R1 through R6. Resident files are maintained at the facility and have the following documents in their files : Admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment/Appraisals, hospice care plans, and emergency information. Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician order for modified diet is on file. Sanitation practices and kitchen cleanliness was observed. Incidental Medical Services: Six (6) centrally stored 30-day supply of medications were reviewed. Medical and dental transportation is provided by facility and family members. Access is also used. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last quarterly fire/emergency drill was completed on 11/1/2023. Residents with SHN : Two (2) residents receive hospice care. Postural support physician orders are on file. Appraisals were observed in resident files. No residents have prohibited health conditions. No deficiencies noted. Exit interview and a copy of this report was provided to House Manager Justina Millan.the state’s words, verbatim · CDSS document, Feb 26, 2024