Shalom House

Type of visit: Office

An Office meeting was conducted today, 03/27/2026, in the Santa Rosa Regional Office. The following individuals were present in the meeting: Acting Regional Manager, Bethany Moellers, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analyst, Caitlynn Felias, Analyst II, Christopher Kovarik, and Licensee, Maria Del Pilar De Olave. The purpose of the office meeting was to discuss the Licensee's lack of an active Administrator certificate. The Department has identified that the Licensee has not had an active Administrator Certificate since 2021. The Application Certification Bureau received a renewal application packet from the Licensee on 12/02/2024 which was approved on 04/10/2025. This application covered the certification period of 2021-2023. Per the Application Certification Bureau, they received a renewal application packet which covered the certification period of 2023-2025 in February 2026 which brought Administrator to current as of 12/07/2025. Another application packet for the certification period of 2025-2027 is required in order to become current with their Administrator certificate. Per Licensee, they have completed their units for the certification period of 2025-2027 and will be mailing their documents via mail to the Administrator Certification Bureau on 03/27/2026. Department to follow up with Application Certification Bureau regarding Licensee's Application status once documents are received. Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 27, 2026

Type of visit: POC

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Plan of Correction (POC) visit and met with Licensee, Pilar De Olave. The purpose of the visit is to follow up on a Plan of Correction that was issued on 02/26/2026. On 02/26/2026, the facility was issued a deficiency under Regulation 87405 - Administrator Qualifications and Duties. Plan of Correction was to provide Community Care Licensing with the following: an update on submitting their paperwork to the Application Portal, communicating with the Application Unit regarding their application status, and hiring an Administrator. This update was to be provided to the Department by 03/09/2026. The Department did not receive an update by the agreed upon date. An Informal Office visit has been scheduled for Friday, 03/27/2026 at 2:00PM to discuss the Licensee's lack of active Administrator certificate. A letter with meeting details was provided during visit. Civil Penalties are being assessed at the rate of $100 per day for outstanding deficiencies. A total amount of $1,000.00 has been issued today for failing to correct Title 22 Regulation 87495(a) for the period of 03/10/2026 through 03/19/2026. Exit interview conducted. Copy of report, Civil Penalty Assessment, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 19, 2026

Type of visit: Case Management - Annual Continuation

At approximately 1:15 PM Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Case Management - Annual Continuation for a required 1-year annual inspection started on 10/28/2025 and met with Licensee Maria Del Pilar De Olave. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for two (2), with one (1) Hospice resident currently in care, and is approved for four (4) non-ambulatory residents. At approximately 1:40 PM LPA conducted a review of three (3) resident records. All required documentation present. At approximately 2:00 PM LPA conducted review of three (3) staff records. All required documentation present. At approximately 2:30 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked. Facility does not have a currently certified Administrator (deficiency cited). Licensee was provided with resources on renewing their Administrator certificate or hiring a new Administrator. LPA gathered updated copies of the following documents during this visit: Liability Insurance, LIC500 - Personnel Report, LIC308 - Designation of Responsibility, LIC610E - Emergency Disaster Plan Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Licensee, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Feb 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Mar 9, 2026

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by: Licensee did not comply with the section cited above. Licensee did not ensure that they have an active Administrator Certificate which posed/poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: Licensee to provide LPA with an update regarding the following items: submitting their paperwork via the Application Portal, communicating with the Application Unit regarding their application status, and hiring an Administrator. Update to be provided to LPA by POC Due Date 3/9/2026 by 5:00PM.

Type of visit: Required - 1 Year

At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Pilar De Olave. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 5 residents, where 4 can be non-ambulatory. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 3 Residents in care and 2 staff members on-site. At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:45AM, LPA conducted a walk-though of the facility. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control Plan on file. Facility is a 1 story building with 4 Resident bedrooms, 2 bathrooms, and common spaces. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. Fire extinguishers were last inspected April 2025. During walkthrough, LPA observed multiple instances of unlabeled homemade food in facility fridge (technical assistance issued, LIC9102, regulation 87775(a)). Facility's last emergency/disaster drill was conducted October 2025. At approximately 9:50AM, LPA reviewed resident files. All files were all found to be well organized, thorough and contained the required documentation. Administrator's Certificate for Pilar De Olave (6030062740) has been expired as of December 2021. LPA and Licensee discussed their expired Administrator Certificate. Licensee showed proof of completed CEUs and that paperwork was sent to the Application Bureau to complete their 2023-2025 renewal application by certified mail on 03/25/2025. Continued on LIC809C Continued from LIC809 Licensee agrees to submit their paperwork via the Application Portal and communicate with the Application Unit regarding their status. LPA and Licensee discussed hiring an Administrator until Licensee receives their renewed Administrator Certificate to help them maintain compliance with Title 22 Regulations (deficiency cited, LIC809D, regulation 87405(a)). LPA unable to complete Annual Visit. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC9102 (Technical Violation/Advisory), Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 28, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

At approximately 11:25AM, Licensing Program Analysts (LPAs) Felias and Frank arrived unannounced to continue a 1-Year Required Visit and met with Licensee/Administrator, Pilar De Olave. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 5 residents, where 4 can be non-ambulatory. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 3 Residents in care and 1 staff member on-site. LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs reviewed medications. During review, LPAs observed that 2 of 3 residents' most recent medications were not documented on the log as required. Review of facility's log indicated that facility understands how to document medications appropriately (technical assistance issued, LIC9102, regulation 87465(h)(6)). Facility's last emergency/disaster drill was conducted November 2024. Administrator Certificate for Pilar de Olave (7008943740) was pending with renewal application received of 12/02/2024. Review of staff files did not show that annual training had been conducted for 2024. LPAs spoke with Staff Member 1 (S1) who stated that they have received their 20 hours of annual training as required. Discussion with Licensee/Administrator stated that they have conducted training but did not document it. LPAs discussed with Licensee about the importance of documenting training as required (technical violation issued, LIC9102, 1569.625(b)(2)). The following deficiencies that were cited during visit conducted on 10/12/2023 were addressed during today's visit. LPAs were provided written documentation and the following deficiencies were cleared and plan of corrections letters provided: proof of quarterly emergency disaster drills (Health and Safety Code 1569.695(c)) infection control plan (Regulation 85095.5(c)) administrator certification (Regulation 87405(a)); cited during visit on 10/12/2023 and 10/23/2024 No Deficiencies Cited during Visit. Exit interview conducted. Copy of report and LIC9102 (Technical Advisories/Violations) and Plan of Corrections Letters discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 7, 2025

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff handled resident in a rough manner Questionable death

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint regarding the above allegations and met with Licensee/Administrator, Pilar De Olave. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff handled resident in a rough manner,” and “Questionable death.” Complainant alleged that facility staff roughly placed Resident 1 (R1) on the toilet causing them to hit their head and lose consciousness. Complainant stated that the Fire Department was contacted while R1 was placed in bed and that R1 passed away 10 minutes later. The Department conducted interviews with staff and involved parties. Staff interviews conducted denied that the allegations occurred and stated that residents were not treated in a rude or rough manner. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Interviews conducted with involved parties stated that R1 was not observed to have any visible injuries and did not suspect that abuse occurred at the facility. The Department contacted the City of San Rafael Fire Department and Marin County Fire Department for records related to R1 and the alleged incident. Both departments stated that there are no records available or on file. Review of R1’s documents indicated that they were admitted to Hospice on 10/28/2022 for unspecified sequelae of cerebral infarction. R1’s death certificate stated that they passed from unspecified sequelae of cerebral infarction/cerebral infarction and that no other significant conditions contributed to their death. Based on interviews conducted, documents reviewed, and observations made, the Department was unable to determine if a violation of Title 22 Regulations has occurred. Therefore, the allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 21-AS-20240711104212

Type of visit: Required - 1 Year

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Pilar De Olave. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 5 residents, where 4 can be non-ambulatory. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 3 Residents in care and 1 staff member on-site. At approximately 9:30AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:45AM, LPA conducted a walk-though of the facility. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control Plan on file. Facility is a 1 story building with 4 Resident bedrooms, 2 bathrooms, and common spaces. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. Fire extinguishers were last inspected April 2024. Smoke detectors and carbon monoxide detectors were tested and operational. At approximately 9:50AM, LPA reviewed staff files and resident files. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Administrator's Certificate for Pilar De Olave (6030062740) was expired as of December 2021. Per Licensee, they have been unable to complete their in-person Continued Education Units (CEUs). Licensee informed LPA that they have not submitted an application to the Department to renew their certificate for this reason. LPA informed Licensee to submit their application for renewal. During visit, LPA observed Licensee begin to fill renewal application out (deficiency cited, see LIC809D, regulation 87405(a)). Continued on LIC809C Continued from LIC809 LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Case Management - Deficiencies

At approximately 2:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies visit, and met with Licensee/Administrator, Pilar de Olave. During the course of the Complaint Investigation dated for July 11, 2024, the Department learned that the Facility did not submit written reports to Community Care Licensing (CCL) per regulation. The Department received information that Resident 1 (R1) passed away on 07/03/2024. Licensee confirmed that they did not submit a Death Report or Special Incident Form (LIC624) to CCL timely (deficiency cited, see LIC809D, regulation 87211(a)(1)(D)). LPA and Licensee discussed the importance of reporting incidents in a timely manner. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jul 21, 2024

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidenced by: Based on interview conducted and record review, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee provided copy of Death Report for R1 during visit. Licensee to submit self-certification stating that they understand the regulation requiring that reports are submitted timely to the Department by POC due date of 07/21/2024.

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by Administrator/Licensee Pilar. There is a total of 2 residents, none have a diagnostic of dementia and no residents currently on Hospice. LPA toured the facility on 10/12/2023 at 9:10 AM with Pilar - licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 4/11/2023 at the time of the visit. Smoke detectors and carbon monoxide detector were found to be operational during the visit. Hot water temperature measured between 115 degrees F and 115.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 10/12/2023. The facility serves residents with dementia and has a plan of operation for special care and programming. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked hallway closet. The bathrooms designated for residents at the facility were supplied with hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 10/12/2023. A review of two resident & three staff records and licensee/administrator as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:00 AM on 10/12/2023 and learned that 2 of 2 residents have updated appraisals/needs & care plans and physician’s assessment (LIC 602A). Medications were centrally stored in locked cabinet in the facility kitchen area, although some were pre-poured (TV given). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/12/2023. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete. Continue LIC 809-C LPA reviewed a sample of staff records 10/12/2023 at 11:00 AM and learned that 1 of 4 facility staff (S1) who require caregiver background checks have not received a criminal record clearances or exemptions and have been working at facility since 9/1/2023 (see LIC809-D & LIC421BG for $500 Civil Penalties). Direct care staff has no proof of annual training requirements for 2022/2023 on file (see LIC809-D). Facility also did not have proof of 2 of 4 staff’s Health Screening or TB test (see LIC809-D). Facility was able to present LPA with proof of CPR for 4 out of 4 staff & 1st Aid certifications for 4 out of 4 staff that files were reviewed. Maria Del Pilar de Olave Administrator Certification # 6030062740 expired on 12/7/2022 and has not renewed (see LIC809-D). LPA reviewed Licensing Information System (LIS) with licensee/administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have not been conducted quarterly as required by Emergency and Preparedness Health & Safety Code. (see LIC 809-D) & or submitted required Infection Control Plan (LIC809-D) Civil Penalties of $500 given for staff working at facility without obtaining background clearance for over 1 month. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Continue on LIC 809-C LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/31/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Certificate of Liability Insurance Copy of Administrator Certificatethe state’s words, verbatim · CDSS document, Oct 12, 2023

The state marks this report as 19 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.