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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601079
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:21:54 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220422103424
FACILITY NAME:OLIVIA'S CARE HOME IIIFACILITY NUMBER:
415601079
ADMINISTRATOR:DE GUZMAN, PATRICIAFACILITY TYPE:
740
ADDRESS:317 W 20TH AVENUETELEPHONE:
(650) 638-0352
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Annalissa Condez and Olivia De GuzmanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Untrained staff are administering insulin to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Jeung met with staff and administrator. LPA also reviewed client files; per MD reports, none of the residents is diabetic nor requires insulin injections.

Based on this investigation, this complaint allegation is determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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