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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200192
Report Date: 10/20/2022
Date Signed: 10/20/2022 05:33:14 PM

Document Has Been Signed on 10/20/2022 05:33 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
CENTRAL COAST CR/RES, 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:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Olga Atienza-BilanTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Licensee, Olga Atienza-Bilan.

During visit, LPA toured the facility to include the resident bedrooms, staff bedroom, bathrooms, office, living room, kitchen, garage, and backyard.Facility has a central entry point for temperature check and visitor sign-in. LPA advised to create a symptom screening questionnaire to initiate at entry for all visitors, staff, and residents. Visitor guidelines posted at entry. Hand sanitizer made available at entry. Bathroom #1 supplied with hygiene products. LPA advised to place a hand washing sign and paper towels. LPA asked Licensee to remove all shared cloth towels in the bathrooms. Bathroom #2 supplied with hygiene products and paper towels. LPA advised to place a hand washing sign next to the bathroom sink. LPA did not observe a complete supply of Personal Protective Equipment (PPE). LPA reviewed facility's infection control plan. Staff are not N95 fit tested. Documents obtained during visit to include facility's LIC-500.

LPA observed an individual residing at the facility without association.

A deficiency was cited during today’s visit, see LIC 809-D. A civil penalty is being assessed for the amount of $100, for staff S1 residing at the facility without association. Please see LIC 421BG. Advisory notes provided.

This report was reviewed with Licensee, Olga Atienza-Bilan and a copy of the report will be emailed to the Licensee due to technical difficulties with the LPA's printer.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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Document Has Been Signed on 10/20/2022 05:33 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/20/2022 at 05:05 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OLGA'S CARE HOME FOR THE ELDERLY
FACILITY NUMBER: 435200192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
(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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 ensure to transfer S1's criminal record to the Department prior to residing at the facility which poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee will review and understand section 87355. Licensee will send the Department via fax S1's LIC9182 and copy of their ID/DL by 10/20/2022. Licensee will send S1 for a live scan, ASAP and send proof to LPA and LPM 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
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