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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605898
Report Date: 02/03/2026
Date Signed: 02/03/2026 05:15:31 PM

Document Has Been Signed on 02/03/2026 05:15 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OLYMPIC BOARD & CAREFACILITY NUMBER:
197605898
ADMINISTRATOR/
DIRECTOR:		JURATE EZERSKIENEFACILITY TYPE:
740
ADDRESS:4532 ABBEY PL.TELEPHONE:
(323) 936-1018
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 6CENSUS: 5DATE:
02/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:56 AM
MET WITH:AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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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)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/03/2026 05:15 PM - It Cannot Be Edited


Created By: Luis DeLeon On 02/03/2026 at 04:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement was not met as evidenced by: S4 did not have record of criminal clearance . This poses an immediate risk to the health, safety, or personal rights of persons in care.
POC Due Date: 02/04/2026
Plan of Correction
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Staff 4 shall apply and be cleared for criminal clearance before returning to work.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/03/2026 05:15 PM - It Cannot Be Edited


Created By: Luis DeLeon On 02/03/2026 at 04:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in five (5) out of five (5) resident medication records where there was no written prescription order from a physician, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Licensee shall obtain a written prescription order from residents R1-R5 physicians indicating the residents prescription. Licencese shall provide the physician orders for R1-R5 to CCLD by POC date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in three (3) out of five (5) residents records where medical assessment for R2-R4 were not done within the last year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Licensees shall obtain medical assessment for R2-R4 and submitt medicall assessment to CCLD by POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2026 05:15 PM - It Cannot Be Edited


Created By: Luis DeLeon On 02/03/2026 at 04:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, there are no current logs for emergency drills conducted, last emergency drill logged was 03/05/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Licensee shall submit documentation of the drill which shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill, by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898
VISIT DATE: 02/03/2026
NARRATIVE
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC809 (FAS) - (06/04)
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