197606902-2-6-2024-31-AS-MVAO-D2N2LM-20240220162945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606902
Report Date: 02/06/2024
Date Signed: 02/06/2024 03:00:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240205141026

FACILITY NAME:	OLIVE BRANCH ASSISTED LIVING, THE		FACILITY NUMBER:	197606902
ADMINISTRATOR:	CHARLES ARRIETA		FACILITY TYPE:	740
ADDRESS:	10215 BALBOA BLVD.		TELEPHONE:	(818) 368-8581
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	146	CENSUS: 83	DATE:	02/06/2024
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Charles Arrieta		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff abandoned resident

INVESTIGATION FINDINGS:

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On 02/06/24, at 10:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator-Charles Arrieta. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, interviews and deliver findings for this complaint.

The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:45am, LPA toured the physical plant, conducted staff interviews, obtained the following record review: Unusual Incident/Injury Report, 30-Day Eviction Notice (SB781), and Olive Branch House Rules.

LIC 9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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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Control Number 31-AS-20240205141026

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OLIVE BRANCH ASSISTED LIVING, THE	FACILITY NUMBER: 197606902
	VISIT DATE: 02/06/2024

NARRATIVE

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Regarding the allegation: Staff abandoned resident. It’s being alleged that RP when dropped off at West LA Medical Center was not allowed to go back to the facility. RP stated that they was never given an eviction notice and was just left at the hospital.

According to the staff interviews, RP was given an eviction notice on 04-28-2023 and signed it the same day. LPA was also able to obtain RP's eviction notice which is signed by RP. The eviction notice shows that RP was given a thirty (30) day notice on March 28, 2023 by the assistant administrator. The eviction notice was given to RP because of their serious violation to the house rules of the above facility. According to staff interviews, RP's behavior became increasingly violent and caused a concern to other residents. LPA was also able to obtain the House Rules of the above facility. LPA was also able to interview the resident that RP hit and caused a concern for the care of the other residents. The resident that RP hit informed the LPA that RP threw something at them hitting them on their ear. LPA was able to obtain the Unusual Incident/Injury Report from the resident. RP was also transferred to another facility where they reside now while in the care of the West LA Medical Center and the help of the Veteran Affairs Department. Based on LPA's record reviews, staff interviews, and the interview with the resident RP hit, the allegation(s) above is unsubstantiated at this time.

An exit interview was conducted, no citations were issued for above allegation(s), and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC9099 (FAS) - (06/04)

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