<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800503
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:30:31 PM

Document Has Been Signed on 01/07/2025 01:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SHALOM HOUSEFACILITY NUMBER:
216800503
ADMINISTRATOR/
DIRECTOR:
MARIA DEL PILAR DE OLAVEFACILITY TYPE:
740
ADDRESS:566 WAKEROBIN LANETELEPHONE:
(415) 491-0604
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 5CENSUS: 3DATE:
01/07/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Licensee/Administrator, Pilar De OlaveTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 3