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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605898
Report Date: 02/24/2022
Date Signed: 02/24/2022 06:03:49 PM

Document Has Been Signed on 02/24/2022 06:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OLYMPIC BOARD & CAREFACILITY NUMBER:
197605898
ADMINISTRATOR:JURATE EZERSKIENEFACILITY TYPE:
740
ADDRESS:4532 ABBEY PL.TELEPHONE:
(323) 936-1018
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 6CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Justina MillanTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Facility Staff/ Caregiver Justina Millan and explained the purpose of today's visit.

This is an RCFE with a capacity of six (6). The facility is licensed to serve six (6) non-ambulatory residents, ages 60 years and over. The following was inspected and toured: 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.

LPA and Facility Staff/ Caregiver Justina Millan toured the physical plant inside and outside. LPA observed the facility to be in good repair. Resident rooms were checked and observed to have the required furniture for comfort and safety such as bed frames, dressers, lamps and chairs and all had sufficient lighting. Residents beds have the required linens which were in good condition at the time of the visit. Resident bedrooms had sufficient closet/ storage space. Activity and game supplies were in stock. Adequate supply of linen stored in dining room cabinet with additional towels and blankets. Bathrooms are clean and operational and were observed to be within Title 22 regulations and had the required grab bars in toilets and showers. Toilets and water faucets worked properly. Showers were free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Water temperature properly measured at 110F*. Facility temperature was comfortable. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. 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 residents, fire extinguishers are fully charged. Food supply was observed to contain a (2) day supply of perishables and a (7) day supply of non-perishables that met title 22 guidelines. There was an adequate supply of dishware,
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898
VISIT DATE: 02/24/2022
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utensils and cooking equipment and appliances were in working order. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

The following were observed/inspected:

  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Residents are able to use their private accommodations as isolation rooms if they have private rooms and if residents have shared rooms there are designated rooms to be used as isolation rooms if a COVID-19 positive case should arise.
  • 30 day supply of medication for residents
  • Facility has an adequate amount of PPE and facility has enough PPE for 60 days.
  • Residents were socially distanced according to local public health guidelines.
  • Residents wearing masks.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc).
  • Hand Sanitizer: Available for staff and resident use.
  • Residents temperature's are checked and logged twice a day.
  • Staff temperatures are checked and logged twice a day.
  • Staff are testing weekly for COVID-19 (Surveillance testing) and residents are tested if they are exhibiting any COVID-19 like symptoms.

Exit interview conducted, a copy of this report was provided to Facility Staff/ Caregiver Justina Millan.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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