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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200192
Report Date: 07/01/2022
Date Signed: 07/01/2022 12:43:45 PM

Document Has Been Signed on 07/01/2022 12:43 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:OLGA'S CARE HOME FOR THE ELDERLYFACILITY NUMBER:
435200192
ADMINISTRATOR:ATIENZA-BILAN, OLGAFACILITY TYPE:
740
ADDRESS:954 JUNESONG WAYTELEPHONE:
(408) 272-7040
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 4DATE:
07/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Olga Atienza-BilanTIME COMPLETED:
12:52 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
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Olga Atienza-Bilan.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA Marrufo observed the facility cleaning supply storage and the PPE storage. There was a 30-day PPE supply.

LPA Marrufo toured 1 out of 1 resident bathroom and observed it to have available soap for residents. The water temperature measured at 108 F.

The outdoor exits were clear of obstructions. LPA Marrufo toured 6 out of 6 resident bedrooms. Each resident bedroom had working lights, bedding, and drawers.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Olga Atienza-Bilan and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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 1