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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606902
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:34:27 PM


Document Has Been Signed on 05/18/2022 02:34 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:OLIVE BRANCH ASSISTED LIVING, THEFACILITY NUMBER:
197606902
ADMINISTRATOR:CHARLES ARRIETAFACILITY TYPE:
740
ADDRESS:10215 BALBOA BLVD.TELEPHONE:
(818) 368-8581
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:146CENSUS: 76DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Charles Arrieta TIME COMPLETED:
02:40 PM
NARRATIVE
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On 05/18/22 at 11:40 AM, Licensing Program Analyst (LPA) Joscelyn Martinez, arrived to conducted an unannounced annual inspection at the facility mentioned above. Upon arrival, LPA Martinez was directed to the Administrator’s office by a staff. LPA met with Administrator Charles Arrieta and the purpose of the visit was explained.

A physical tour was conducted at 11:50 AM and observed the following: Infection control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, LPA’s temperature was not taken. There is not a staff designated for Covid-19 Screening. It was informed by the Activity Coordinator and Administrator that covid-19 screening has not been conducted for about two months. LPA observed some staff not wearing masks inside the facility while being in common areas. LPA reminded staff to review all of the Provider Information Pins and Infection Control Regulation for current information. Facility has sufficient PPE supplies for more than 30 days. Fire Alarms are located throughout the facility and have a service date of 11/10/21. Fire extinguishers were observed throughout the facility and were in the green with the service date of 11/09/21. Carbon Monoxide alarms are located throughout the facility and are operable. Common Areas: These include the dining areas, library, hair salon, and activities room. All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 75.0 F. Common bathrooms were observed to have trash cans with lids and Covid Sings posted. Facility has a laundry area and a locked closet where chemicals are stored. Facility has a designated medication room that is inaccessible to residents. Kitchen area was toured and LPA observed there to be sufficient one week non-perishable foods and two days perishable food for all residents. Bedrooms were randomly selected to tour and were observed to have appropriate furniture.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: OLIVE BRANCH ASSISTED LIVING, THE
FACILITY NUMBER: 197606902
VISIT DATE: 05/18/2022
NARRATIVE
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Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested and measured 114 F. Outside areas: LPs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water

Deficiency on 809-D. Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/18/2022 02:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: OLIVE BRANCH ASSISTED LIVING, THE
FACILITY NUMBER: 197606902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited

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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement was not
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met as evidenced by:
Based on observations the licensee/staff did not comply with the cited section by not screening LPA"s for symptoms of COVID 19 upon entry and staff where not wearing masks, which poses and immediate Health and Safety and personal rights risk to persons in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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