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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200192
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:44:03 PM

Document Has Been Signed on 10/23/2024 04:44 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/
DIRECTOR:		ATIENZA-BILAN, OLGAFACILITY TYPE:
740
ADDRESS:954 JUNESONG WAYTELEPHONE:
(408) 272-7040
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Olga Atienza-BilanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPA) Maria (Mita) Partoza and Manuel Monter a conducted an unannounced required 1 year inspection visit and met with licensee/administrator (LIC/ADM) Olga Atienza-Bilan and stated the purpose of the visit.

The facility is licensed to serve adults 60 and over of which 6 may be non-ambulatory and is subject to terms and condition of dementia waiver. LPA observed 5 out of 5 residents are present at the facility that have mild neurocognitive impairment, 1 staff was present during the visit.

At 3:05 p.m. LPAs toured the facility inside and outside with LIC/ADM including but not limited to the kitchen, bathroom, dining room, living room, 5 residents rooms, garage, backyard and exterior walkways. The temperature inside the home was at 73 degrees Fahrenheit.

The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. The refrigerator temperature was at 36 degree Fahrenheit and the freezer was at 22 degree Fahrenheit. LPA discussed with LIC/ADM food safety and storage. Under the sink cabinet is used to store cleaning supply kept locked and not accessible to residents. The water temperature measured at 108 to 112 degrees Fahrenheit. Resident's room (R1 to R5) have sufficient storage.

The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction.

LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is easily accessed by staff.
page 1 of 2 - see LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ELDERLY
FACILITY NUMBER: 435200192
VISIT DATE: 10/23/2024
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The backyard, walkways, ramps and patio are free from debris and obstruction. The facility screen windows were observed to be in good repair. The washer and dryer located at garage are in good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.

LPA reviewed 3 out of 5 resident records such as the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records to be current and updated.

LPA reviewed 2 out of 2 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record clearance/fingerprints. The facility has conducted an fire and earthquake drill on 06/1/2024.

Deficiency was cited during today's visit for based on California Code of Regulations (CCR) Title 22 87555(b)(21). See LIC 809D.

An exit interview was conducted during today's visit with Licensee/administrator Olga Atienza-Bilan. A copy of the report and appeal's rights was provided.

end of report
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2024 04:44 PM - It Cannot Be Edited


Created By: Maria Partoza On 10/23/2024 at 04:09 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: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(21)
87555 General Food Service Requirements (b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above, the freezer temperature was not maintained at 0 degree F (-17.7 degrees C). The refrigerator has a built in digital thermostat and a manual thermostat inside was placed. Both were observed to have the same temperature reading 22 degrees F. Which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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LIC/ADM stated that if the freezer temperature does not regulate within the next 24 hours after removing some of the frozen products, the refrigerator will be replaced. LIC/ADM stated she will submit a written plan action on how the facility will ensure the freezer is maintained at a temperature of 0 degrees F (-17.7 degrees C). ADM stated the POC will be submitted by the 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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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